sign in sign up
<<
Home , Anaplasmosis, Clostridium, Corynebacterium, Ehrlichia ewingii, Shigellosis, Vibrio vulnificus

TEXAS DEPARTMENT OF STATE HEALTH SERVICES Infectious Control Unit

Epi Case Criteria Guide, 2020

Revision date: January 2020

Texas Department of State Health Services

Epi Case Criteria Guide, 2020

Editor

Laura Tabony, MPH

Contributors

Adam Lynch, MPH Johnathan Ledbetter, MPH

Adrienne Fung, MPH Jonathan Kolsin, MPH Anna Nutt, MPH, CIC Kamesha Owens, MPH Bonny Mayes, MA Kelly Broussard, MPH

Briana O’Sullivan, MPH Laura Robinson, DVM, MS Carlos R. Alvarez, MPH, CPH, A-IPC Melba Zambrano, MSN, RN, CIC Eric Garza, MPH Rachael Straver, DVM, MPH Gillian Blackwell, BSN, RN, CIC Sandi Arnold, RN, CIC Greg Leos, MPH, CPH Sepehr Arshadmansab, MPH

Irina Cody, MPH Thi Dang, MPH, CIC

 Texas Department of State Health Services Infectious Disease Control Unit Emerging and Acute Infectious Disease Branch// Control Branch Mail Code 1960 PO Box 149347 Austin, TX 78714-9347 Phone 512.776.7676 • Fax 512.776.7616 Revised: January-October 2020 Publication No. E59-11841

Revision date: January – October 2020 ~ ii REVISIONS MADE FROM THE 2019 TO THE 2020 EPI CASE CRITERIA GUIDE

Changes in scope/name . phagocytophilum to . chaffeensis infection to ( infection) . infection to Ehrlichiosis (Ehrlichia ewingii infection) . Novel coronavirus to Novel Coronavirus 2019 . Spotted group rickettsioses to

Revisions of case criteria for Clinical Description and/or criteria (CD); Confirmed, Probable, Possible, or Suspect cases (CC, PC, PsC, SC); Laboratory Confirmation tests (LC); and Note(s) (N)

. Acute flaccid myelitis ...... CD, CC, PC, SC, LC . Mumps ...... SC . Anaplasmosis ...... CD, LC . Novel coronavirus 2019 ...... CD, CC, PC, SC, LC, N . Ascariasis ...... CD, PC, LC . Pertussis ...... CD, N . -resistant (CRE)...... CD, N . ...... CD, LC, CC, PC, SC, N . Chagas disease, acute ...... PC, N . Prion such as Creutzfeldt-Jakob disease (CJD) ... CD, CC, PC, PsC, N . Chagas disease, chronic indeterminate ...... CC, PC, SC, N . , acute ...... CD, LC, PC . Chagas disease, chronic symptomatic ...... CC, PC, SC, N . Rickettsiosis, unspecified ...... CD, PC, N . Ehrlichiosis (Ehrlichia chaffeensis infection) ...... CD, PC, LC . ...... CD, PC, LC, N . Ehrlichiosis (Ehrlichia ewingii infection) ...... CD . Spotted fever group rickettsioses ...... LC, PC, N . Ehrlichiosis/Anaplasmosis undetermined ...... CD . Trichuriasis ...... CD, LC . (HF) ...... CD, SC, LC, N . Typhus, -borne (endemic, murine) ...... CD, LC, N . Fascioliasis ...... LC . Viral hemorrhagic fever (VHF) Non-Ebola ...... CD, SC . Hookworm (ancylostomiasis) ...... CD, LC . ...... CD, PC, LC, N . Legionellosis ...... CD, PC, LC . Multidrug-resistant Acinetobacter (MDR-A) ...... CD, N

Revision date: January – October 2020 ~ iii ~

TABLE OF CONTENTS

This document provides infectious disease information for surveillance and data entry staff. It contains a table with condition codes, condition names, and case criteria to aid in the classification and coding of conditions. It is organized alphabetically by condition name. Conditions specified as reportable in Title 25, Texas Administrative Code, Chapter 97, Subchapter A, Control of Communicable Diseases are in bold type. Click on a condition in the table of contents to go to the text and on the condition code to move back.

Editor ...... ii Contributors ...... ii REVISIONS MADE FROM THE 2019 TO THE 2020 EPI CASE CRITERIA GUIDE ...... ii Table of Contents ...... iv Definition of Terms ...... vii Abbreviations ...... viii Notes ...... ix

CASE CRITERIA ...... 10

Acute Flaccid Myelitis ...... 10 Amebiasis ...... 10 Am Amebic meningitis/encephalitis, other...... 11 Amebic meningoencephalitis, primary (PAM) ...... 12 Anaplasmosis (Anaplasma phagocytophilum infection) ...... 12 ...... 13 Arbovirus, neuroinvasive (encephalitis/meningitis) and non-neuroinvasive ...... 14 Ascariasis ...... 15 Ba ...... 16 , foodborne...... 17 Botulism, infant...... 17 Botulism, other unspecified ...... 17

Botulism, ...... 17 ...... 18 ...... 18 Ca Carbapenem-resistant Enterobacteriaceae (CRE) ...... 19 Chagas disease, acute ...... 20 Chagas disease, chronic indeterminate ...... 20 Chagas disease, chronic symptomatic ...... 21 Chickenpox - (see Varicella) ...... 21 Co (toxigenic cholerae O1 or O139) ...... 21 Contaminated sharps injury ...... 22 Cryptosporidiosis ...... 23 Cyclosporiasis ...... 23

Cysticercosis ...... 24 Dengue–like Illness ...... 24 Dengue ...... 24 Ea Dengue, severe ...... 24 ...... 26 Eh Ebola (HF) ...... 27 Echinococcosis ...... 28 En Ehrlichiosis ( ...... 28 Ehrlichiosis (Ehrlichia ewingii infection) ...... 29 Revision date: January – October 2020 ~ iv ~

Ehrlichiosis/Anaplasmosis – undetermined ...... 29 , Shiga -producing (STEC) ...... 29 Ha Fascioliasis ...... 30 Granulomatous amebic encephalitis (GAE) ...... 30 Group A , invasive (GAS) ...... 30 Group B Streptococcus, invasive (GBS) ...... 30

Haemophilus influenzae, invasive disease ...... 30 Hep Hantavirus infection, non-HPS ...... 31 Hantavirus pulmonary syndrome...... 31 Hemolytic uremic syndrome, post-diarrheal (HUS) ...... 32 A, acute ...... 32 Hepatitis B, acute ...... 33 Ma Hepatitis B virus infection, perinatal ...... 33 Hepatitis C, acute ...... 34 Hepatitis E, acute ...... 35 Hookworm (ancylostomiasis) ...... 35 Influenza, human isolates - [outbreaks only] ...... 36 Influenza A, novel/variant ...... 37 #x23456- Influenza-associated pediatric mortality...... 38 drug Legionellosis ...... 39 resistant Leishmaniasis ...... 39 Acinetobacte ...... 40 ...... 41 r Malaria ...... 42 P Measles (Rubeola) ...... 42 Meningococcal infection, invasive () ...... 43 Multidrug-resistant Acinetobacter (MDR-A) ...... 44 Multidrug-resistant (MDRO) (See specific for definition) ...... 44 Mumps ...... 45 R Norovirus - [outbreaks only] ...... 45 Novel Coronavirus 2019 (January through May 19, 2020) ...... 46 Novel Coronavirus 2019 (May 20, 2020 – October 2020)...... 47 Novel Coronavirus 2019 (November 2020) ...... 48 Sa Outbreaks, exotic diseases, and unusual expression of disease ...... 49 Paragonimiasis ...... 50

Pertussis ...... 50 Plague ...... 51 Poliomyelitis, paralytic ...... 52 Poliovirus infection, nonparalytic ...... 52 Primary amebic meningoencephalitis (PAM) ...... 52 Error! Prion diseases such as Creutzfeldt-Jakob disease (CJD) ...... 53 Bookmark Q Fever, acute ...... 56 not defined.St Q Fever, chronic ...... 56 Rabies, ...... 57 Rabies, human ...... 57 Rickettsiosis, unspecified ...... 58 Rubella ...... 58

Rubella, congenital syndrome ...... 59 Salmonella Paratyphi ...... 59 Salmonella Typhi ...... 60 , non-Paratyphi/non-Typhi ...... 60 Revision date: January – October 2020 ~ v ~

Shiga toxin-producing Escherichia coli (STEC) ...... 61 ...... 62 Smallpox ...... 62 Spotted fever rickettsiosis ...... 63 Streptococcal toxic syndrome (Outbreaks only) ...... 64 Streptococcus, invasive group A (GAS) disease () ...... 65

Streptococcus, invasive group B (GBS) disease () ...... 65 , invasive disease (IPD) ...... 66 Taenia solium and undifferentiated Taenia infection ...... 66 ...... 66 Trichinellosis (Trichinosis) ...... 67 Trichuriasis ...... 67 ...... 68 Typhus, flea-borne (endemic, murine) ...... 69 Typhus fever (epidemic, louse-borne)...... 70 -intermediate (VISA) ...... 70 Vancomycin-resistant Staphylococcus aureus (VRSA) ...... 71 Varicella (chickenpox) ...... 71

Vibrio parahaemolyticus ...... 72 ...... 72 Vibriosis, other or unspecified ...... 73 Viral Hemorrhagic Fever (VHF) non-Ebola * ...... 73 Yellow fever ...... 74 Yersiniosis ...... 74 Zika disease, congenital ...... 75 Zika disease, non-congenital ...... 76 Zika infection, congenital...... 77 Zika infection, non-congenital ...... 78

Revision date: January – October 2020 ~ vi ~

DEFINITION OF TERMS

Clinically compatible case: Medical history and/or generally compatible with the disease, as described in the clinical description

Confirmed case: A case that is classified as confirmed for reporting purposes Culture-independent diagnostic testing: The detection of antigen or nucleic acid sequences of the

Epidemiologically linked case: A case in which a) the patient has had contact with one or more persons who either have/had the disease or have been exposed to a point source of infection (i.e., a single source of infection, such as an event leading to a foodborne-disease outbreak, to which all confirmed case-patients were exposed) and b) transmission of the agent by the usual modes of transmission is plausible . A case can be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed.

Laboratory-confirmed case: A case that is confirmed by one or more of the laboratory methods listed in the case definition under Laboratory Confirmation Tests While other laboratory methods can be used in clinical diagnosis, only those listed are accepted as laboratory confirmation for national and state reporting purposes. Probable case: A case that is classified as probable for reporting purposes

Supportive or presumptive laboratory results: Specified laboratory results that are consistent with the diagnosis, yet do not meet the criteria for laboratory confirmation

Suspect case: A case that is classified as suspect for reporting purposes Normally sterile site: Invasive diseases typically cause significant morbidity and mortality. Sterile sites include: . Blood (excluding cord blood) . Bone or bone marrow . Cerebrospinal fluid (CSF) . Pericardial fluid . Peritoneal fluid . Pleural fluid

The following are also considered sterile sites when certain other criteria are met: . Internal body sites (brain, heart, liver, spleen, vitreous fluid, kidney, pancreas, lymph node or ovary) when the specimen is collected aseptically during a surgical procedure . Joint fluid when the joint surface is intact (no or significant break in the skin)

Although placentas and amniotic fluid from an intact amnion are not considered sterile sites, isolation of Group B streptococci or from these sites may qualify as invasive disease. Consult the Sterile Site and Invasive Disease Determination flowchart in Appendix A of the EAIDB Investigation Guidelines for more information: https://www.dshs.texas.gov/IDCU/investigation/Investigation-Guidance/

Normally sterile sites do not include: . Anatomical areas of the body that normally harbor either resident or transient flora () including mucous membranes (e.g., throat, vagina), sputum, and skin; ; or localized soft infection

Table of Contents

Revision date: January – October 2020 ~ vii ~

ABBREVIATIONS

LABORATORY TEST ABBREVIATIONS HEPATITIS TEST MARKERS CF – Complement fixation Hepatitis A – HAV CIDT – Culture-independent diagnostic testing Anti-HAV – hepatitis A antibody CLSI – Clinical and Laboratory Standards Institute Anti-HAV IgM – hepatitis A IgM antibody CSF – Cerebrospinal fluid Hepatitis B – HBV DFA – Direct fluorescent antibody HBcAb or anti-HBc – hepatitis B core antibody DNA – Deoxyribonucleic acid HBc IgM or anti-HBc IgM – hepatitis B core IgM antibody EEG – Electroencephalogram HBeAb or anti-HBe – hepatitis B e antibody EIA – immunoassay HBeAg – hepatitis B e antigen ELISA – Enzyme-linked immunosorbent assay HBsAb or anti-HBs – hepatitis B surface antibody HA – Hemagglutination HBsAg – hepatitis B surface antigen HI – Hemagglutination inhibition Hepatitis C – HCV ID – Immunodiffusion Anti HCV – hepatitis C antibody IFA – Indirect fluorescent antibody test HCV RNA – hepatitis C nucleic acid IgG – Immunoglobulin G HCV NAT – hepatitis C nucleic acid testing IgM – Immunoglobulin M HCV RIBA – hepatitis C recombinant immunoblot assay IHA – Indirect hemagglutination Hepatitis D – HDV IHC – Immunohistochemistry Anti-HDV – hepatitis D antibody LA – Latex agglutination Hepatitis E – HEV MA –- Microagglutination Anti-HEV IgM – hepatitis E IgM antibody MIC – Minimum inhibitory concentration MRI – Magnetic resonance imaging OTHER ABBREVIATIONS: NAT – Nucleic acid testing ALT – Alanine transaminase PCR – Polymerase chain reaction ARDS – Acute Respiratory Distress Syndrome PRNT – Plaque reduction neutralization test AST – Aspartate transaminase RIBA – Recombinant immunoblot assay CDC – Centers for Disease Control and Prevention RIPA – Radio-immune precipitation assay DSHS – Department of State Health Services rRT-PCR – Real-time reverse transcriptase-polymerase chain reaction EAIDB – Emerging and Acute Infectious Disease Branch RT-PCR – Reverse transcription polymerase chain reaction FDA – Food and Drug Administration WB – Western blot ILI – Influenza-Like Illness NDM-1 – New Delhi Metallo-beta-lactamase-1 NPDPSC – The National Prion Disease Pathology Surveillance Center TAC – Texas Administrative Code VHF – Viral hemorrhagic fever

Table of Contents

Revision date: January – October 2020 ~ viii ~

NOTES

Rickettsia Classification The classification of into three groups (spotted fever, typhus, and ) was based on serology. This grouping has since been confirmed by DNA sequencing except for R. felis which is genetically more closely related to the spotted fever group Rickettsia. The human are included in the following conditions. Spotted fever group rickettsioses is defined by antigenic group (spotted fever group) and vector (). Flea-borne (murine) typhus contains flea-borne of both the typhus (R. typhi) and spotted fever (R. felis) groups. (R. prowazekii) belongs to the typhus group and is louseborne. Scrub typhus (, formerly classified as R. tsutsugamushi), a scrub typhus group species transmitted by , and (R. akari), a spotted fever group species transmitted by mites, are not reportable. A table classifying rickettsial species known to cause disease in humans by antigenic group, disease, primary vector, and reservoir occurrence can be found in the CDC’s Traveler’s Health Yellow Book at https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/rickettsial-spotted-and-typhus--and-related--including-anaplasmosis-and-ehrlichiosis.

Streptococcus Classification Streptococci are facultatively anaerobic, gram-positive organisms that often occur as chains or pairs. There are four different classification systems for Streptococcus species, clinical (pyogenic, oral, enteric), (alpha-hemolysis, beta-hemolysis, gamma-hemolysis), serological (Lancefield: A-H and K-U), and biochemical (physiological). Lancefield group Streptococci are subdivided into groups by antibodies that recognize surface antigens. The serologic reactivity of " wall" polysaccharide “C” antigens was described by Rebecca Lancefield. Twenty group-specific antigens were established, Lancefield A-H and K-U. Clinically significant Lancefield groups include A, B, C, F, and G. Some streptococci such as Streptococcus pneumoniae and the are Lancefield group nontypeable. Hemolytic reaction The type of hemolytic reaction displayed on blood agar has also been used to classify the streptococci. Beta-hemolysis is associated with complete lysis of red cells surrounding the colony, whereas alpha-hemolysis is a partial or "green" hemolysis associated with reduction of red cell hemoglobin. Nonhemolytic colonies have been termed gamma-hemolytic. The property of hemolysis is not very reliable for the absolute identification of streptococci, but it is widely used in rapid screens for identification. Reportable Streptococcus Group A Streptococcus (GAS, Streptococcus pyogenes) - Lancefield Group A streptococci are nearly always beta-hemolytic. Group B Streptococcus (GBS, Streptococcus agalactiae) - Lancefield Group B streptococci are usually beta-hemolytic, but can also be alpha or gamma hemolytic. Streptococcus pneumoniae (pneumococcus) - Most strains of S. pneumoniae are alpha-hemolytic but can cause ß-hemolysis during anaerobic incubation. They are nontypeable by Lancefield group.

Table of Contents

Revision date: January – October 2020 ~ ix ~

CASE CRITERIA

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Acute Flaccid Myelitis An illness with onset of acute flaccid limb weakness (low muscle tone, limp, hanging . A magnetic resonance image (MRI) showing 11120 loosely, not spastic or contracted) of one or more limbs. spinal cord lesion largely restricted to gray matter* and spanning one or more vertebral Confirmed: A case that meets the clinical symptoms AND confirmatory laboratory/imaging segments, evidence in the absence of a clear alternative diagnosis attributable to a nationally notifiable . Excluding persons with gray matter lesions condition. in the spinal cord resulting from physician Probable: A case that meets the clinical symptoms AND presumptive laboratory/imaging diagnosed malignancy, vascular disease, or evidence in the absence of a clear alternative diagnosis attributable to a nationally notifiable anatomic abnormalities. condition. * Terms in the spinal cord MRI report such Presumptive laboratory/imaging evidence: as “affecting mostly gray matter,” “affecting . MRI showing spinal cord lesion where gray matter involvement is present, but the anterior horn or anterior horn cells,” predominance cannot be determined, “affecting the central cord,” “anterior . Excluding persons with gray matter lesions in the spinal cord resulting from physician myelitis,” or “poliomyelitis” would all be diagnosed malignancy, vascular disease, or anatomic abnormalities. consistent with this terminology. Suspect: A case that meets the clinical symptoms AND available information is insufficient to classify case as probable or confirmed.

Amebiasis Infection of the by Entamoeba histolytica can vary in severity, ranging Intestinal amebiasis 11040 from mild, chronic to fulminant . Infection may also be . Demonstration of cysts or trophozoites of asymptomatic. Extraintestinal infection can occur (e.g., hepatic abscess). E. histolytica in stool, Confirmed, intestinal amebiasis: A clinically compatible illness that is laboratory OR confirmed . Demonstration of trophozoites in tissue biopsy or scrapings by culture or Suspect, intestinal amebiasis: A clinically compatible case with E. histolytica detected histopathology in stool by use of an antigen-based fecal immunoassay Extra-intestinal amebiasis Confirmed, symptomatic extraintestinal amebiasis: A symptomatic person (with . Demonstration of E. histolytica trophozoites clinical or radiographic findings consistent with extraintestinal infection) and in extraintestinal tissue demonstration of specific antibody against E. histolytica as measured by reliable immunodiagnostic test (e.g., EIA) and PCR based assays Confirmed, asymptomatic extraintestinal amebiasis: A case with demonstration of the organism, E. histolytica, in at least one extra-intestinal tissue sample

10 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Amebic An infection presenting as meningoencephalitis or encephalitis. Granulomatous amebic Detection of Acanthamoeba, Balamuthia, or meningitis/encephalitis, other encephalitis (GAE) can include general symptoms and signs of encephalitis such as another non-Naegleria free-living ameba from 10096 early personality and behavioral changes, depressed mental status, fever, photophobia, a clinical specimen or culture via: , nonspecific cranial nerve dysfunction, and visual loss. GAE neurologic . Detection of nucleic acid (e.g., PCR), infections are generally fatal within weeks or months; however, a few patients have OR survived. . Detection of antigen (e.g., Confirmed: A clinically compatible case that is laboratory confirmed immunohistochemistry) Note: Acanthamoeba species and Balamuthia mandrillaris can also cause disseminated Contact the DSHS epidemiologist for disease (affecting multiple organ systems) or cutaneous disease. For B. mandrillaris meningitis (amebic) at 800-252-8239 if disease, painless skin lesions appearing as plaques a few millimeters thick and one to suspected. DSHS can assist in coordinating several centimeters wide have been observed in some patients, especially patients specimen and/or electronic images outside the U.S., preceding the onset of neurologic symptoms by 1 month to submission to the CDC for verification. approximately 2 years. Skin lesions and sinus disease may be seen in Acanthamoeba Collection & shipping procedures can be found at: disease. Disseminated disease and cutaneous disease caused by free-living amebae are http://www.cdc.gov/parasites/acanthamoeba/ only voluntarily reportable in Texas unless they progress to meningitis or encephalitis. and See also Amebic meningoencephalitis, primary (PAM) http://www.cdc.gov/parasites/balamuthia/ Note: Acanthamoeba spp. and B. mandrillaris can cause clinically similar illnesses and might be difficult to differentiate using commonly available laboratory procedures. Definitive diagnosis by a reference laboratory might be required. A negative test on CSF does not rule out Acanthamoeba or Balamuthia infection because these organisms are not commonly present in the CSF.

11 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Amebic meningoencephalitis, An infection presenting as meningoencephalitis or encephalitis. The clinical presentation Detection of from a clinical primary (PAM) of PAM is like that of acute meningitis caused by other pathogens and symptoms specimen via: 80750 include headache, nausea, vomiting, anorexia, fever, lethargy, and stiff neck. . Detection of nucleic acid (e.g., PCR), Disorientation, mental status changes, activity, loss of consciousness, and ataxia OR may occur within hours of initial presentation. After the onset of symptoms, the disease . Detection of antigen (e.g., progresses rapidly and usually results in death within 3 to 7 days. immunohistochemistry) Confirmed: A clinically compatible case that is laboratory confirmed Notes: Probable: A clinically compatible case that meets at least one of the supportive . When available, molecular characterization laboratory criteria (listed below) and does not meet confirmatory lab criteria [e.g., genotype] should be reported. . Contact the DSHS epidemiologist for  Supportive laboratory evidence: amebic meningitis at 800-252-8239 if o Visualization of motile amebae in a wet mount of CSF suspected. DSHS can assist in coordinating o Isolation of N. fowleri in culture from a clinical specimen specimen and/or electronic images See also Amebic meningitis/encephalitis, other submission to the CDC for verification. . Collection & shipping procedures can be found at: http://www.cdc.gov/parasites/naegleria/diag nosis-hcp.html . Naegleria fowleri might cause clinically similar illness to bacterial meningitis, particularly in its early stages. Definitive diagnosis by a reference laboratory is required. Unlike Balamuthia mandrillaris and Acanthamoeba spp., N. fowleri is commonly found in the CSF of patients with PAM.

Anaplasmosis (Anaplasma Anaplasmosis is a tick-borne illness caused by the bacterium Anaplasma phagocytophilum, . Demonstration of a four-fold change in IgG- phagocytophilum infection) which is transmitted primarily by blacklegged ( spp.). Initial symptoms may include specific antibody titer to A. phagocytophilum 11090 fever/chills, headache, myalgia, nausea/vomiting and diarrhea. Anaplasmosis may result in antigen by IFA in paired serum samples severe illness or even death in older or immunocompromised individuals or if treatment is (preferably one taken in first week of illness delayed. and a second taken 2-4 weeks later), Clinical evidence: Fever as reported by patient or provider and one or more of the following: OR headache, myalgia, , , , or any hepatic transaminase . Detection of A. phagocytophilum DNA in a elevation. clinical specimen by PCR, Confirmed: A clinically compatible illness that is laboratory confirmed OR . Demonstration of anaplasmal antigen in a Probable: A clinically compatible illness with serological evidence of IgG or IgM antibody biopsy/autopsy sample by IHC, reactive (>1:128) with A. phagocytophilum antigen by IFA, OR identification of morulae in the OR cytoplasm of neutrophils or eosinophils by microscopic examination . Isolation of A. phagocytophilum from a Suspect: A case with laboratory evidence of past/present infection with A. phagocytophilum clinical specimen in cell culture (e.g., laboratory report) but no available clinical information

12 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Anthrax An illness or post-mortem examination characterized by several distinct clinical forms, . Culture and identification of 10350 including : anthracis or B. cereus expressing anthrax . Cutaneous: A skin lesion evolving during a period of 2-6 days from a papule, from clinical specimens by the through a vesicular stage, to a depressed black eschar. Fever, malaise, and Laboratory Response Network, can accompany the lesion. OR . Inhalation: A prodrome resembling a viral respiratory illness, followed by hypoxia . Demonstration of B. anthracis antigens in and dyspnea, or acute respiratory distress syndrome (ARDS) with resulting cyanosis tissues by IHC using both B. anthracis cell and shock. Radiographic evidence of mediastinal widening or pleural effusion is wall and capsule monoclonal antibodies, common. OR . Ingestional presents as two sub-types: . Evidence of a four-fold rise in antibodies . Gastrointestinal: Severe and tenderness, nausea, vomiting, to protective antigen between acute and hematemesis, bloody diarrhea, anorexia, fever, and septicemia. convalescent sera or a fourfold change in . Oropharyngeal: Mucosal lesion in the oral cavity or oropharynx, with cervical antibodies to protective antigen in paired adenopathy, edema, , fever, and possible septicemia. convalescent sera using CDC quantitative . Injectional: Severe soft tissue infection manifested as significant edema or bruising anti-PA IgG ELISA testing in an after injection. No eschar is apparent and pain is not common. Nonspecific unvaccinated person, symptoms such as fever, shortness of breath and nausea are sometimes the first indication of illness. OR . Systemic involvement: Fever, convulsions, , tachypnea, hypotension, . Detection of Lethal Factor (LF) in clinical leukocytosis, and meningeal signs (anthrax meningitis). These complications may be serum specimens by LF mass spectrometry secondary to the above syndromes. OR . Detection of B. anthracis or Clinical criteria: A clinically compatible illness with at least one specific OR two non- by the LRN-validated PCR and/or specific symptoms and signs that are compatible with cutaneous, ingestion, inhalation, sequencing in clinical specimens collected or injection anthrax; systemic involvement; or anthrax meningitis; OR a death of from a normally sterile site or lesion of unknown cause AND organ involvement consistent with anthrax. other affected tissue Confirmed: A case that meets clinical criteria AND has confirmatory laboratory test Note: As required by TAC, all B. anthracis results. isolates must be submitted to the DSHS Probable: A case that meets clinical criteria AND has a demonstrating Laboratory. B. cereus expressing anthrax Gram-positive rods, square-ended, in pairs or short chains; OR a positive result on a test toxin isolates should be forwarded for with established performance in a CLIA-accredited laboratory; OR has epidemiologic confirmation. linkage relating it to anthrax. Suspect: A case that mets the clinical criteria AND for whom an anthrax test was ordered, but with no epidemiologic linkage relating it to anthrax. Epidemiologic linkage is defined as one or more of the following: . Exposure to environment, food, animal, materials, or objects that is suspected or confirmed to be contaminated with B. anthracis; OR . Exposure to the same environment, food, animal, materials, or objects as another person who has lab-confirmed anthrax; OR . Consumption of the same food as another person who has laboratory-confirmed anthrax.

13 Revision date: January – October 2020

Arbovirus, neuroinvasive For the purposes of surveillance and reporting, arboviral disease cases are often Neuroinvasive (encephalitis/meningitis) and categorized into two primary groups based on their clinical presentation: neuroinvasive . Isolation of virus from, or demonstration of non-neuroinvasive disease and non-neuroinvasive disease. Many arboviruses cause neuroinvasive disease specific viral antigen or nucleic acid in, such as aseptic meningitis, encephalitis, or acute flaccid paralysis (AFP). These illnesses tissue, blood, CSF, or other body fluid, Neuroinvasive Disease are usually characterized by the acute onset of fever with stiff neck, altered mental OR 10058 Encephalitis, Cache Valley 10054 Encephalitis, California status, seizures, limb weakness, CSF pleocytosis, and/or abnormal neuroimaging. Less Four-fold or greater change in virus-specific serogroup virus common neurological manifestations, such as cranial nerve palsies, also occur. AFP is quantitative antibody titers in paired sera, 10053 Encephalitis, Eastern characterized by rapid-onset extremity, facial, and/or respiratory weakness and flaccid OR equine (EEE) muscle tone in the affected area; AFP may result from anterior myelitis, peripheral . Virus-specific IgM antibodies in serum 10078 Encephalitis, Jamestown Canyon neuritis or post-infectious peripheral demyelinating neuropathy (Guillain-Barré with confirmatory virus-specific 10059 Encephalitis, Japanese Syndrome). Meningitis is infection or inflammation of the tissues surrounding the brain; neutralizing antibodies in the same or a 10081 Encephalitis, La Crosse symptoms can include fever, headache, photophobia, and nuchal rigidity. Encephalitis is later specimen, and negative neutralizing 10057 Encephalitis, Powassan infection or inflammation of the brain tissue itself and may present with fever, altered antibody results for potentially cross- 10051 Encephalitis, St. Louis (SLE) mental status, seizures, and focal neurologic deficits; meningitis may also be present reactive* arboviruses endemic to the 10074 Encephalitis, tick-borne simultaneously, known as meningoencephalitis. Most arboviruses are capable of causing region where exposure occurred, 10055 Encephalitis, Venezuelan an acute systemic febrile illness (e.g., West Nile fever) that may include headache, OR equine (VEE) myalgias, arthralgias, rash, and/or gastrointestinal symptoms. Some viruses also can . Virus-specific IgM antibodies in CSF and a 10056 Encephalitis, West Nile (WNND) cause more characteristic clinical manifestations, such as severe polyarthralgia or negative result for other IgM antibodies in 10052 Encephalitis, Western arthritis due to chikungunya virus or other alphaviruses. CSF for potentially cross-reactive* equine (WEE) Clinical evidence of neuroinvasive disease: arboviruses endemic to the region where Non-neuroinvasive Disease . Meningitis, encephalitis, acute flaccid paralysis, or other acute signs of central or exposure occurred 99999 Arbovirus, other peripheral neurologic dysfunction, as documented by a physician, AND Non-neuroinvasive 10066 Cache Valley virus . Absence of a more likely clinical explanation . Isolation of virus from, or demonstration of 10061 California serogroup virus Clinical evidence of non-neuroinvasive disease: specific viral antigen or nucleic acid in, tissue, 10073 Chikungunya virus 10093 . Fever or chills as reported by the patient or a health-care provider, AND blood, or other body fluid, excluding CSF, 10062 Eastern equine encephalitis . Absence of neuroinvasive disease, AND OR virus . Absence of a more likely clinical explanation Four-fold or greater change in virus-specific 10079 Jamestown Canyon quantitative antibody titers in paired sera, 10068 Japanese encephalitis virus Neuroinvasive: 11712 Keystone virus Confirmed: A clinically compatible case (meets neuroinvasive clinical evidence OR 10082 La Crosse virus criteria) with laboratory confirmation . Virus-specific IgM antibodies in serum 10063 with confirmatory virus-specific Probable: A clinically compatible case (meets neuroinvasive clinical evidence criteria) 11734 Snowshoe hare virus neutralizing antibodies in the same or a 10064 St. Louis encephalitis virus with virus-specific IgM antibodies in CSF or serum but no other testing OR with lower later specimen and negative neutralizing 11724 Trivittatus virus levels of neutralizing antibodies for potentially cross-reactive* arboviruses endemic antibody results for potentially cross- 10067 Venezuelan equine to the region where exposure occurred*. encephalitis virus reactive* arboviruses endemic to the 10049 West Nile fever Non-neuroinvasive: region where exposure occurred 10065 Western equine Confirmed: A clinically compatible case (meets non-neuroinvasive clinical evidence encephalitis virus *Viruses in the same (the majority of criteria) with laboratory confirmation pathogenic arboviruses are in the flavivirus, Probable: A clinically compatible case (meets non-neuroinvasive clinical evidence alphavirus, or orthobunyavirus genus) are criteria) with virus-specific IgM antibodies in serum but no other testing OR with lower generally considered potentially cross- levels of neutralizing antibodies for potentially cross-reactive* arboviruses endemic reactive. Consider area of exposure, clinical to the region where exposure occurred manifestations of each arbovirus, and level Note: If lab evidence, clinical manifestations, and exposure history cannot distinguish of arbovirus activity when assessing which between two arboviruses, the case should be reported as “Arbovirus, other.” viruses must be ruled out. 14 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Ascariasis A parasitic infection caused by the soil-transmitted helminths Ascaris lumbricoides and . Microscopic identification of Ascaris spp. 80770 Ascaris suum. Most infections with Ascaris spp. are asymptomatic. Live worms, passed in (A.lumbricoides or A.suum) eggs in , stools or occasionally from the mouth, anus, or nose, are often the first recognized sign of OR infection. Larval migration may result in pulmonary manifestations such as wheezing, . Microscopic identification of ascarid larvae cough, fever, eosinophilia and pulmonary infiltration in some patients. Mild infections may in sputum or gastric washings, result in minor abdominal discomfort, dyspepsia, and loss of appetite. Major infections may OR result in severe abdominal pain, fatigue, vomiting, or weight loss. In children, these . Identification of A. lumbricoides or A.suum symptoms can result in nutrient deficiencies resulting in growth retardation and/or cognitive adult worms passed from the anus, mouth, impairment. Serious complications are rare but can be fatal and include intestinal obstruction or nose by a bolus of worms, or obstruction of bile duct, pancreatic duct or appendix by one or more adult worms. Confirmed: A case that is laboratory confirmed Probable: A clinically compatible case with evidence of infection such as . An ultrasound showing Ascaris spp. worms in the pancreas or liver, OR . CT scans or MRI showing Ascaris spp. worms present in the ducts of the liver or pancreas.

15 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Babesiosis Babesiosis is a parasitic disease caused by organisms in the Babesia genus. Infection can At least one of the following must be met: 12010 range from subclinical to life-threatening. Clinical manifestations can include hemolytic . Identification of intraerythrocytic Babesia anemia and nonspecific influenza-like signs and symptoms (e.g., fever, chills, sweats, organisms by light microscopy in a Giemsa, headache, myalgia, arthralgia, malaise, fatigue, and generalized weakness), splenomegaly, Wright, or Wright-Giemsa–stained blood hepatomegaly, or jaundice. Laboratory findings can include thrombocytopenia, proteinuria, smear, hemoglobinuria, and elevated levels of liver , blood urea nitrogen, and creatinine. OR Severe cases can be associated with marked thrombocytopenia, disseminated intravascular . Detection of Babesia spp. DNA in a whole coagulation, hemodynamic instability, acute respiratory distress, myocardial infarction, renal blood specimen by PCR, failure, hepatic compromise, altered mental status, and death. OR Objective Clinical Criteria: 1) fever; 2) anemia; 3) thrombocytopenia . Detection of Babesia spp. genomic Subjective Clinical Criteria: 1) sweats, 2) headache, 3) myalgia, 4) arthralgia, 5) chills sequences in a whole blood specimen by Confirmed: A clinically compatible case that is laboratory confirmed AND meets at least one nucleic acid amplification, objective clinical criterion OR one subjective clinical criterion OR . Isolation of Babesia organisms from a whole Probable: A case that: blood specimen by animal . Has at least one supportive laboratory result (criteria listed below) AND meets at least one objective clinical criterion (subjective clinical criteria alone are not sufficient) . IFA total immunoglobulin (Ig) or IgG titer: . B. microti: ≥1:256 (≥1:64 in epidemiologically linked blood donors or recipients) . B. divergens: ≥1:256 . B. duncani: ≥1:512 . Immunoblot IgG: B. microti positive result, OR . Is a blood donor or recipient epidemiologically linked to a confirmed or probable babesiosis case, AND . Has confirmatory laboratory evidence but does not satisfy objective or subjective clinical criterion, OR . Satisfies the supportive laboratory criteria (same as above) Suspect: A case that has confirmatory or supportive laboratory results, but insufficient clinical or epidemiological information is available for case classification

16 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Botulism, foodborne Ingestion of results in an illness of variable severity. Common symptoms are . Detection of botulinum toxin in serum, stool, 10530 diplopia, blurred vision, and bulbar weakness. Symmetric paralysis can progress rapidly. or patient's food,

Confirmed: A clinically compatible case that is laboratory confirmed or that occurs among OR persons who ate the same food as persons who have laboratory confirmed botulism . Isolation of botulinum from stool Probable: A clinically compatible case with a history of ingestion of a food item known to carry a risk for the botulism toxin Note: As required by TAC all isolates must be submitted to the DSHS Laboratory.

Botulism, infant An illness of infants, characterized by constipation, poor feeding, and “failure to thrive” that . Detection of botulinum toxin in stool or 10540 can be followed by progressive weakness, impaired respiration, and death. serum, OR Confirmed: A clinically compatible case that is laboratory confirmed, occurring in a child . Isolation of Clostridium botulinum from aged less than 1 year stool Note: As required by TAC all Clostridium botulinum isolates must be submitted to the DSHS Laboratory.

Botulism, other unspecified Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are . Detection of botulinum toxin in clinical 10548 diplopia, blurred vision, and bulbar weakness. Symmetric paralysis can progress rapidly. specimen, OR Confirmed: A clinically compatible case that is laboratory confirmed in a patient aged . Isolation of Clostridium botulinum from greater than or equal to 1 year who has no history of ingestion of suspect food and has no clinical specimen Note: As required by TAC all Clostridium botulinum isolates must be submitted to the DSHS Laboratory.

Botulism, wound An illness resulting from toxin produced by Clostridium botulinum that has infected a . Detection of botulinum toxin in serum, 10549 wound. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric OR paralysis can progress rapidly. . Isolation of Clostridium botulinum from Confirmed: A clinically compatible case that is laboratory confirmed in a patient who has no wound suspected exposure to contaminated food and who has a history of a fresh, contaminated wound during the 2 weeks before onset of symptoms, or a history of injection drug use Note: As required by TAC all Clostridium within the 2 weeks before onset of symptoms botulinum isolates must be submitted to the Probable: A clinically compatible case in a patient who has no suspected exposure to DSHS Laboratory. contaminated food and who has either a history of a fresh, contaminated wound during the 2 weeks before onset of symptoms, or a history of injection drug use within the 2 weeks before onset of symptoms

17 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Brucellosis An illness that can cause a range of clinical signs and symptoms. Initial signs and symptoms . Culture and identification of Brucella spp. 10020 may include fever, sweats, malaise, anorexia, headache, myalgia, arthralgia and/or fatigue. from clinical specimens, Chronic signs and symptoms may include recurrent fevers, arthritis, epididymitis, orchitis, OR , hepatomegaly, splenomegaly, neurologic symptoms, chronic fatigue, and/or . Four-fold or greater rise in Brucella depression. agglutination titer between acute- and Confirmed: A clinically compatible illness that is laboratory confirmed convalescent-phase serum specimens Probable: A clinically compatible case with at least one of the following: obtained greater than or equal to 2 weeks . Epidemiologically linked to a confirmed human or animal brucellosis case, OR apart and studied at the same laboratory . Brucella total antibody titer ≥1:160 by standard tube agglutination test (SAT) or by Note: As required by TAC, all Brucella spp. Brucella microagglutination test (BMAT) in one or more serum specimens obtained after isolates must be submitted to the DSHS onset of symptoms, OR Laboratory. . Detection of Brucella DNA in a clinical specimen by PCR assay

Campylobacteriosis An illness of variable severity commonly manifested by diarrhea, abdominal pain, . Isolation of Campylobacter spp. in a clinical 11020 nausea and sometimes vomiting. The organism may also rarely cause extra-intestinal specimen infections such as bacteremia, meningitis or other focal infections. Confirmed: A case that is laboratory confirmed Probable: . A case with Campylobacter spp. detected. in a clinical specimen using a culture independent diagnostic test (CIDT) OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Notes: . The use of CIDTs as stand-alone tests for the direct detection of Campylobacter in stool is increasing. Data regarding their performance indicate variability in the sensitivity, specificity, and positive predictive value of these assays depending on the manufacturer (CDC unpublished data). It is therefore useful to collect information on the laboratory conducting the testing using the laboratory’s unique CLIA number, and when possible, type and manufacturer of the CIDT used to diagnose each case. Culture confirmation of CIDT-positive specimens is ideal, but not practical to achieve in most jurisdictions. . A case should not be counted as a new case if laboratory results were reported within 30 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different species.

18 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Carbapenem-resistant Carbapenem-resistant Enterobacteriaceae (CRE): Carbapenem-resistant . Any Klebsiella species, E. aerogenes, or Enterobacteriaceae (CRE) Enterobacteriaceae, specifically Klebsiella species and Escherichia coli, are gram- E. coli that is: 77924 negative that are resistant to carbapenem . Carbapenemase producing . Resistant to any carbapenem, including Enterobacteriaceae have the ability to break down the carbapenem rendering meropenem, , doripenem, or it ineffective. Carbapenem resistance by Enterobacteriaceae can occur by many , different mechanisms, such as KPC and NDM, which can be transmitted from one Enterobacteriaceae to another. OR . Positive for known carbapenemase Although Enterobacter species can be resistant to carbapenem antibiotics, resistance (i.e. KPC, NDM, VIM, Enterobacter species are not included in this CRE definition. , IMP, OXA-48), previously known as Enterobacter aerogenes, does meet the case definition. OR CRE can colonize or infect any body site. The most common types of CRE . Positive on a phenotypic test for infections include bloodstream infections, ventilator-associated , and carbapenemase production by metallo- intra-abdominal abscesses. β-lactamase test, modified Hodge test Confirmed: A Klebsiella species, E. aerogenes, or E. coli from any body site that is (MHT), Carba NP, Carbapenem laboratory confirmed. Inactivation Method (CIM) or modified CIM (mCIM). Note: Additional information on CRE can be found at http://www.cdc.gov/HAI/organisms/cre/index.html Note: There is no requirement to submit isolates to the DSHS Laboratory. Please contact a DSHS HAI Epidemiologist or the DSHS lab for additional information on available lab support. If the CRE isolate is sent to the DSHS lab for additional testing, use the submitting lab’s antibiotic susceptibility testing results to meet the epi case criteria.

19 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Chagas disease, acute Chagas disease is a parasitic infection caused by Trypanosoma cruzi. The acute phase is . Identification of T. cruzi by microscopy 12041 characterized by the first 8 weeks of infection, detectable parasitemia, and asymptomatic including: (most common) or symptomatic manifestations of disease which can include any of the . Microscopic examination of T. cruzi by: following: Fever, malaise, rash, body aches, headache, loss of appetite, vomiting, . Wet mount – motile trypanosomes diarrhea, hepatomegaly, splenomegaly, lymphadenopathy, Chagoma (nodular swelling OR at site of inoculation), Romaña’s sign (unilateral swelling of the eyelid), acute . Thick & thin smears - Giemsa stain myocarditis, and/or meningoencephalitis. OR Confirmed: A case (asymptomatic or symptomatic) that has confirmatory laboratory testing. . Detection of T. cruzi DNA by PCR Asymptomatic individuals must have evidence of parasitemia based on microscopy or PCR. OR . Positive diagnostic serology confirmed by Probable A clinically compatible case with positive diagnostic serology for T. cruzi IgG testing at CDC antibodies in a sample collected within 8 weeks of illness onset. Note: Congenital infections are considered Notes: acute up to 8 weeks of age and can be . T. cruzi IgM tests are unreliable and are thus insufficient evidence of infection. diagnosed by confirmatory tests. Infants <12 . Samples forwarded to CDC for confirmatory testing which test negative cannot be months and epidemiologically-linked need classified as cases. to be retested after 12 months of age. . Please refer to the DSHS website for guidance on Chagas disease testing: http://www.dshs.texas.gov/IDCU/disease/Chagas/humans/

Chagas disease, chronic Following the acute phase, most infected people enter into a prolonged, asymptomatic . Detection of antibody specific to T. cruzi indeterminate form of disease (called “chronic indeterminate”) during which few or no parasites are by TWO distinct diagnostic tests 12043 found in the blood. During this time, most people are unaware of their infection. Many performed at CDC people remain asymptomatic for life and never develop chronic Chagas-related symptoms. Note: No single supportive test has the Confirmed: An asymptomatic case >12 months of age with confirmatory lab results sensitivity and specificity to be relied on Probable: An asymptomatic case >12 months of age with positive diagnostic serology alone, thus two different methods or for T. cruzi IgG antibodies antibodies specific to T. cruzi are used. Suspect: An asymptomatic case ≥12 months of age with positive (reactive) blood donor screening Notes: . Samples forwarded to CDC for confirmatory testing which test negative cannot be classified as cases. . Patients with positive diagnostic serology should have confirmatory testing performed at the CDC. . Patients with positive blood donor screening should have T. cruzi IgG testing at a commercial lab. . Women with chronic indeterminate disease can transmit infection to their unborn babies. Infants <12 months of age with a mother from an endemic area, in absence of direct detection of the organism, cannot be classified or ruled out due to maternal antibodies; perform serology at 12 months of age and classify based on presence or absence of symptoms as chronic symptomatic or chronic indeterminate case definition. . Please refer to the DSHS website for guidance on Chagas disease testing: http://www.dshs.texas.gov/IDCU/disease/Chagas/humans/

20 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Chagas disease, chronic Much like the chronic indeterminate phase, the chronic symptomatic phase of disease . Detection of antibody specific to T. cruzi symptomatic (more than 8 weeks post infection) is characterized by undetectable parasitemia. by TWO distinct diagnostic tests 12042 However, an estimated 20 - 30% of infected people will develop debilitating and performed at CDC sometimes life-threatening medical problems over the course of their lives. Note: No single supportive test has the Complications of chronic Chagas disease may include heart rhythm abnormalities that sensitivity and specificity to be relied on can cause sudden death, a dilated heart that doesn’t pump blood well, and/or a dilated alone, thus two different methods or esophagus or colon, leading to difficulties with eating or passing stool. antibodies specific to T. cruzi are used. Confirmed: A clinically compatible case of physician-diagnosed chronic Chagas disease in a patient >12 months of age with confirmatory laboratory results Probable: A clinically compatible case of physician-diagnosed chronic Chagas disease in a patient >12 months of age with positive diagnostic serology for T. cruzi IgG antibodies Suspect: A clinically compatible case of physician-diagnosed chronic Chagas disease in a patient ≥12 months of age with positive (reactive) blood donor screening Notes: . Samples forwarded to CDC for confirmatory testing which test negative cannot be classified as cases. . Patients with positive diagnostic serology should have confirmatory testing performed at the CDC. . Patients with positive blood donor screening should have T. cruzi IgG testing at a commercial lab. . Women with chronic indeterminate disease can transmit infection to their unborn babies. Infants < 12 months of age with a mother from an endemic area, in absence of direct detection of the organism, cannot be classified or ruled out due to maternal antibodies; perform serology at 12 months of age and classify based on presence or absence of symptoms as chronic symptomatic or chronic indeterminate case definition. . Please refer to the DSHS website for guidance on Chagas disease testing: http://www.dshs.texas.gov/IDCU/disease/Chagas/humans/

Chickenpox - (see See Varicella Varicella)

Cholera (toxigenic Vibrio An illness characterized by diarrhea and/or vomiting; severity is variable. . Isolation of toxigenic (i.e., - cholerae O1 or O139) producing) O1 or O139 Confirmed: A clinically compatible illness that is laboratory confirmed 10470 from stool or vomitus, Note: Illnesses caused by strains of V. cholerae other than toxigenic V. cholerae O1 or O139 OR should not be reported as cases of cholera. (See , Vibrio vulnificus, . Serologic evidence of recent infection and Vibriosis, other or unspecified) Note: As required by TAC all Vibrio species isolates must be submitted to the DSHS Laboratory. 21 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Contaminated sharps injury A contaminated sharps injury that occurs in a heath care setting that is contaminated with Both source person and injured employee human blood or body fluids should be reported per the below guidelines. should be tested for HIV, HBV, and HCV due Contaminated sharps injuries in private facilities must be documented per OSHA guidelines. to the exposure and not as a laboratory confirmation. Table of Contents http://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html See referenced U.S. Public Health Service Contaminated sharps injuries in Texas public facilities (government entities) are reported to DSHS Emerging and Acute Infectious Disease Branch. Guidelines for recommended follow-up testing. The facility where the injury occurred should complete the reporting form and submit it to the local health authority where the facility is located. If no local health authority is appointed for this jurisdiction, submit to the regional director of the Texas Department of State Health Services (TDSHS) regional office in which the facility is located. Address information for regional directors can be obtained at http://www.dshs.state.tx.us/regions/default.shtm. The local health authority, acting as an agent for the TDSHS will receive and review the report for completeness, and submit the report to: Texas Department of State Health Services Emerging and Acute Infectious Disease Branch PO Box 149347 (Mail Code 1960), Austin, Texas 78714-9347 Fax number: 512-776-7616 The reporting forms can be found at http://www.dshs.state.tx.us/idcu/health/infection_control/bloodborne_pathogens/reporting/

For health care worker HIV risk assessment and follow-up refer to the Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis http://stacks.cdc.gov/view/cdc/20711 (updated 2013). For health care worker HBV and HCV risk assessment and follow-up refer to the Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Post-exposure Prophylaxis (updated 2001).

22 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Cryptosporidiosis A gastrointestinal illness characterized by diarrhea and one or more of the following: . Detection of Cryptosporidium organisms or 11580 diarrhea duration of 72 hours or more, abdominal cramping, vomiting, or anorexia. DNA in stool, intestinal fluid, tissue samples, Confirmed: A case that is laboratory confirmed biopsy specimens, or other biological sample by certain laboratory methods with a high Probable: positive predictive value (PPV), e.g., DFA, . A case with Cryptosporidium antigen detected by a screening test method such as, the PCR, EIA, or light microscopy of stained immunochromatographic card/rapid card test or a laboratory test of unknown method specimen OR . A clinically compatible case that is epidemiologically linked to a confirmed case by one of the following means: . Household or other close contact to a lab-confirmed case with onset of symptoms within 1 month (before or after), OR . Exposure to an outbreak at a body of water or water facility involving at least 2 lab-confirmed cases and onset of symptoms within one month (before or after) of one or more of these cases Note: A case should not be counted as a new case if laboratory results were reported within 365 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection

Cyclosporiasis An illness of variable severity caused by the protozoan parasite Cyclospora . Detection — in symptomatic or 11575 cayetanensis. The most common symptom is watery diarrhea. Other common symptoms asymptomatic persons — of Cyclospora: include loss of appetite, weight loss, abdominal /bloating, nausea, body aches, . Oocysts in stool by microscopic and fatigue. Vomiting and low grade fever also may be noted. Relapses and examination, or in intestinal fluid/aspirate asymptomatic infections can occur. or intestinal biopsy specimens, Confirmed: A laboratory-confirmed case with or without clinical symptoms OR . Demonstration of sporulation, Probable: A clinically compatible case that is epidemiologically linked to a confirmed case OR . DNA (by PCR) in stool, intestinal Note: A case should not be counted as a new case if laboratory results were reported within fluid/aspirate or intestinal biopsy 365 days of a previously reported infection in the same individual, unless additional specimens information is available indicating a separate infection

23 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Cysticercosis Cysticercosis is a tissue infection caused by the larval form of the pork tapeworm, . Diagnosis of neurocysticercosis is usually 12031 Taenia solium. Infection occurs when the tapeworm eggs are ingested, hatch into larvae, made by MRI or CT brain scans in order and migrate to tissues where they form cysticerci (cysts). The signs and symptoms of to identify the presence of cysticerci. If cysticercosis reflect the development of cysticerci in various sites. Subcutaneous surgery is necessary, confirmation of the cysticerci may be visible or palpable. diagnosis can be made by demonstrating When cysticerci are found in the brain, the condition is called neurocysticercosis, which the cysticercus in the tissue involved can cause diverse manifestations including seizures, mental disturbances, focal (biopsy). neurologic deficits, and signs of space-occupying intracerebral lesions. Death can occur . Radiographs can identify calcified suddenly. Extracerebral cysticercosis can cause ocular, cardiac, or spinal lesions with cysticerci in tissues other than the brain. associated signs and symptoms. Asymptomatic subcutaneous nodules and calcified intramuscular nodules can be encountered. Confirmed: Laboratory confirmation of the presence of cysticercus in tissue Notes: . Documentation of biopsy or imaging results is required. . Demonstration of T. solium eggs and proglottids in the feces are diagnostic of taeniasis (see Taenia solium and undifferentiated Taeniasis), not cysticercosis. Persons who are found to have eggs or proglottids in their feces should be evaluated serologically since autoinfection, resulting in cysticercosis, can occur. . Blood tests are available to help diagnose an infection, but are not always accurate. While suggestive, it does not necessarily prove that cysticercosis is present. Dengue–like Illness Dengue is a potentially fatal febrile illness caused by infection with any of the four dengue . Detection of DENV nucleic acid in serum, 11704 viruses (DENV-1, -2, -3 and -4). Dengue is transmitted primarily through the bite of Aedes plasma, CSF, other body fluid or tissue by aegypti and Ae. albopictus mosquitoes. For the purposes of surveillance and reporting, validated RT-PCR, Dengue based on their clinical presentation, dengue cases can be categorized into three primary 10680 OR groups: dengue-like illness, dengue, and severe dengue. Detection of DENV antigen in tissue, by IHC, Dengue, severe Clinical evidence of dengue-like illness: OR 11705 . Fever as reported by the patient or healthcare provider . Detection in serum or plasma of DENV NS1 antigen by a validated immunoassay, Clinical evidence of dengue: OR . Fever as reported by the patient or healthcare provider and the presence of one or more . Cell culture isolation of DENV from serum, of the following signs and symptoms: plasma, or CSF specimen, . nausea/vomiting . rash OR . aches and pains (i.e. headache, retro-orbital pain, arthralgia) . Detection of IgM anti-DENV in serum or CSF . tourniquet test positive in a traveler returning from a dengue endemic . leukopenia (a total <5,000/mm³) area without ongoing transmission of another . abdominal pain flavivirus, clinical evidence of co-infection . persistent vomiting with a flavivirus or recent against . extravascular fluid accumulation a flavivirus, . mucosal bleeding OR . liver enlargement >2 centimeters . Detection of IgM anti-DENV in serum or CSF . increasing hematocrit concurrent with rapid decrease in platelet count in a person living in a dengue endemic or non-

24 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests endemic area of the US without evidence of Clinical evidence of severe dengue: other flavivirus transmission, . Dengue with any one or more of the following scenarios: OR . severe plasma leakage evidenced by hypovolemic shock and/or extravascular . IgM anti-DENV seroconversion by fluid accumulation with respiratory distress validated immunoassay in acute (i.e., . severe bleeding from the or vagina as defined by collected <5 days of illness onset) and requirement for medical intervention including intravenous fluid resuscitation convalescent (i.e., collected >5 days after or blood transfusion illness onset) serum specimens, . severe organ involvement, including any of the following: OR . elevated liver transaminases: aspartate aminotransferase (AST) or . IgG anti-DENV seroconversion or ≥4-fold alanine aminotransferase (ALT) ≥1,000 units per liter (U/L) rise in titer in serum specimens collected >2 . impaired level of consciousness and/or diagnosis of encephalitis, weeks apart, and confirmed by a encephalopathy, or meningitis neutralization test (e.g., plaque reduction . heart or other organ involvement including myocarditis, , neutralization test) with a >4-fold higher and pancreatitis end point titer as compared to other Confirmed: A clinically compatible case of dengue-like illness, dengue, or severe dengue with flaviviruses tested confirmatory laboratory results Probable: A clinically compatible case of dengue-like illness, dengue, or severe dengue AND one of the following: . Detection of IgM anti-DENV by validated immunoassay in serum or CSF in a person living in a dengue endemic or non-endemic area of the US with evidence of other flavivirus transmission or recent vaccination against a flavivirus . Detection of IgM anti-DENV by validated immunoassay in serum or CSF in a traveler returning from a dengue endemic area with ongoing transmission of another flavivirus, clinical evidence of co-infection with one of these flaviviruses, or recent vaccination against a flavivirus Suspect: A clinically compatible case of dengue-like illness, dengue, or severe dengue with an epidemiologic linkage*, as defined below: *Epidemiologic linkage criteria: . Travel to a dengue endemic country or presence at a location with an ongoing outbreak within the previous two weeks of onset of an acute febrile illness or dengue, OR . Association in time and place with a confirmed or probable dengue case

25 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Diphtheria An upper respiratory tract illness with an adherent membrane of the nose, , tonsils, or . Isolation of diphtheriae 10040 larynx OR an infection of a non-respiratory anatomical site (e.g., skin, wound, conjunctiva, from a clinical specimen, ear, genital mucosa) AND

Confirmed: A clinically compatible case that is either laboratory confirmed, OR . Confirmation of toxin-production by Elek epidemiologically linked to a laboratory-confirmed case test or by another validated test capable of confirming toxin-production OR An infection at a non-respiratory anatomical site (e.g., skin, wound, conjunctiva, ear, genital mucosa) with: . Isolation of toxin-producing Corynebacterium diphtheriae from that site Notes: . PCR and MALDI-TOF (matrix assisted laser desorption/ionization-time of flight mass spectrometry) diagnosis for C. diphtheria, when used alone, do not confirm toxin production. These tests, when used, should always be combined with a test that confirms toxin production, such as the Elek test. . Individuals without evidence of clinical criteria as described by the diphtheria surveillance case definition but for whom toxin-producing C. diphtheria is confirmed via laboratory testing (isolation and toxigenicity testing by modified Elek test or other validated test capable of confirming toxin-production) should not be classified as cases. These individuals are considered carriers of the bacteria and are not reportable.

26 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Ebola (HF) An illness characterized by abrupt onset of fever and usually accompanied by one or more of . Detection of Ebola virus by RT-PCR, 11630 the following symptoms: severe headache, fatigue, myalgia (muscle pain), vomiting, OR diarrhea, abdominal pain, or unexplained bleeding or bruising (hemorrhage). Other . Isolation of Ebola virus in culture, symptoms and clinical findings may include weakness, nausea, arthralgia, red eyes, sore OR throat, hiccups, skin rash, symptoms of impaired kidney and liver function, elevated liver . Detection of Ebola virus by Ebola virus enzymes, low white blood cell count, or low platelet count (thrombocytopenia). antigen-capture ELISA, OR Confirmed: A clinically compatible illness that is laboratory confirmed . Detection of Ebola virus antigen by Suspect ( Person Under Investigation (PUI)): A person that meets the clinical criteria AND Immunohistochemistry (IHC) one or more of the epidemiologic risk factors within 21 days of onset of symptom onset: Clinical Criteria: . Fever, AND* . One or more of the following symptoms: severe headache, fatigue, myalgia (muscle pain), vomiting, diarrhea, abdominal pain, or unexplained bleeding or bruising (hemorrhage) Epidemiologic Risk Factor Criteria: . Direct contact with blood or body fluids of a person who is sick with or has died from Ebola Virus Disease (EVD), OR . Direct contact with objects (such as clothes, bedding, needles and syringes) contaminated with blood or body fluids from a person who is sick with or has died from EVD, OR . Direct contact with non-human primates or fruit bats infected with Ebola virus, OR . Exposure to semen of an individual who recovered from EVD within the last 12 months or breast-milk of an individual who had EVD within the last 6 months, OR . Handling EVD specimens in a laboratory setting, OR . Residence in - or travel to - an EVD endemic area or area currently classified by CDC as an Ebola outbreak area *During an Ebola outbreak period, fever is not required to meet the PUI (suspect) case definition. Although the clinical case criteria may not require fever to be present, at least one other Ebola-compatible symptom, and an epidemiologic risk factor must be present to meet the PUI (suspect) case definition. These scenarios will be reviewed on a case by case basis.

27 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Echinococcosis Echinococcosis is an infection caused by the larval stage of tapeworms in the genus . Detection of cysts or organ lesions using 80670 Echinococcus, including E. granulosus and E. multilocularis. Transmission occurs imaging techniques, including CT, MRI, and through the ingestion of tapeworm eggs in contaminated food, water, soil, dog feces, or ultrasonography AND detection of on the contaminated coats of dogs and cats. Infection may also occur through the Echinococcus-specific antibodies, ingestion of cysts in the undercooked internal organs of infected intermediate hosts, OR such as sheep, goats and swine. Many infections are asymptomatic for years before the . Detection of Echinococcus spp. DNA by growing cysts cause clinical signs and symptoms associated with the affected organs. PCR in a clinical specimen, Liver involvement is associated with abdominal pain, hepatic masses, and biliary duct OR obstruction. Pulmonary involvement can produce chest pain, cough, and hemoptysis. . Histopathology or parasitology results Other organs, including the brain, bone, and heart, may also be involved with resulting compatible with Echinococcus spp. (i.e., clinical signs and symptoms. Ruptured cysts may cause fever, urticaria (hives), direct visualization of the protoscolex in cyst eosinophilia and anaphylactic shock. fluid) Confirmed: An asymptomatic or symptomatic case that meets one or more confirmatory laboratory criteria. Probable: An asymptomatic or symptomatic case with Echinococcus-specific antibodies identified by TWO different types of serological assays.

Ehrlichiosis (Ehrlichia Ehrlichiosis is a group of tick-borne diseases caused by ehrlichiae, obligate intracellular . Demonstration of a four-fold change in IgG- chaffeensis infection) bacteria that infect peripheral blood leukocytes. Ehrlichia chaffeensis is transmitted by the specific antibody titer to E. chaffeensis 11088 bite of infected lone star ticks. Initial symptoms may include fever/chills, headache, myalgia, antigen by IFA in paired serum samples nausea/vomiting, confusion, and rash. E. chaffeensis disease may result in severe illness or (preferably one taken in first week of illness even death in older or immunocompromised individuals or if treatment is delayed. and a second taken 2-4 weeks later), Clinical evidence: Fever as reported by patient or provider and one or more of the following: OR headache, myalgia, anemia, leukopenia, thrombocytopenia, or any hepatic transaminase . Detection of E. chaffeensis DNA in a clinical elevation. specimen by PCR, Confirmed: A clinically compatible illness that is laboratory confirmed OR . Demonstration of ehrlichial antigen in a Probable: A clinically compatible illness with serological evidence of IgG or IgM antibody biopsy/autopsy sample by IHC, reactive (>1:128) with E. chaffeensis antigen by IFA, OR identification of morulae in the OR cytoplasm of monocytes or macrophages by microscopic examination . Isolation of E. chaffeensis from a clinical specimen in cell culture Suspect: A case with laboratory evidence of past/present infection with E. chaffeensis (e.g., laboratory report) but no available clinical information

28 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Ehrlichiosis (Ehrlichia Ehrlichiosis is a group of tick-borne diseases caused by ehrlichiae, obligate intracellular . Detection of E. ewingii DNA in a clinical ewingii infection) bacteria that infect peripheral blood leukocytes. Ehrlichia ewingii is transmitted by the bite specimen by PCR 11089 of infected lone star ticks. Symptoms are similar to that of E. chaffeensis disease; however Note: Because the organism has never been gastrointestinal symptoms are less common, rash is rare, and fewer severe manifestations cultured, antigens are not available. Thus, E. have been reported. ewingii infections can only be diagnosed by Clinical evidence: Fever as reported by patient or provider and one or more of the following: molecular detection methods. headache, myalgia, anemia, leukopenia, thrombocytopenia, or any hepatic transaminase elevation. Confirmed: A clinically compatible illness that is laboratory confirmed Suspect: A case with laboratory evidence of past/present infection with E. ewingii (e.g., laboratory report) but no available clinical information

Ehrlichiosis/Anaplasmosis – There are at least three species of intracellular bacteria responsible for Not applicable - See note undetermined ehrlichiosis/anaplasmosis in the US (Ehrlichia chaffeensis, E. ewingii, and Anaplasma 11091 phagocytophilum). The clinical signs of disease that result from infection with these bacteria are similar, their geographic ranges overlap, and serologic cross-reactions may occur among tests for these agents. Clinical evidence: Fever as reported by patient or provider and one or more of the following: headache, myalgia, anemia, leukopenia, thrombocytopenia, or any hepatic transaminase elevation. Probable: A clinically compatible illness with serological evidence of IgG or IgM antibody reactive (>1:128) with Ehrlichia/Anaplasma spp. by IFA OR identification of morulae in white cells by microscopic examination in the absence of other supportive lab results Suspect: A case with laboratory evidence of past/present infection with undetermined Ehrlichia/Anaplasma spp. but no available clinical information Note: For ehrlichiosis/anaplasmosis, an undetermined case can only be classified as probable. This occurs when a case has compatible clinical criteria with laboratory evidence to support infection, but not with sufficient clarity to identify the organism as E. chaffeensis, A. phagocytophilum, or E. ewingii. This can include the identification of morulae in white cells by microscopic examination in the absence of other supportive laboratory results.

Escherichia coli, - See Shiga toxin-producing Escherichia coli (STEC) producing (STEC)

29 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Fascioliasis Fascioliasis (liver fluke trematode) is transmitted by eating raw watercress or other . Microscopic identification of Fasciola eggs 80663 water plants contaminated with immature larvae, usually from locations around sheep, in feces, duodenal contents, or bile, cattle, or related . The immature larval flukes migrate through the intestinal wall, OR the abdominal cavity, and the liver tissue, into the bile ducts, where they develop into . Microscopic identification of a Fasciola mature adult flukes. In the early (acute) phase, symptoms may include fever; adult fluke extracted from a clinical gastrointestinal problems such as nausea, vomiting and diarrhea; a swollen liver specimen (e.g. bile ducts), (hepatomegaly); liver function abnormalities, skin rashes; shortness of breath; and OR abdominal pain or tenderness. The chronic phase (after the parasite settles in the bile . Detection of Fasciola coproantigens ducts), is marked by inflammation and hyperplasia and thickening of the bile ducts and (antigens found in feces) by ELISA gall bladder, leading to biliary lithiasis or obstruction. The symptoms of this phase such as biliary colic, nausea, intolerance to fatty food, right upper quadrant pain, epigastric pain, obstructive jaundice, and pruritus, are the result of a blockade in the biliary tract and inflammation in the gall bladder. Inflammation of the liver, gallbladder, and pancreas can also occur. Confirmed: A case that is laboratory confirmed Probable: A clinically compatible case with . Detection of Fasciola antibodies, OR . History of ingestion of watercress or freshwater plants and eosinophilia

Granulomatous amebic See Amebic meningitis/encephalitis, other encephalitis (GAE)

Group A Streptococcus, See Streptococcus, invasive group A (GAS) invasive (GAS) Group B Streptococcus, See Streptococcus, Invasive group B (GBS) invasive (GBS) influenzae, Invasive may manifest as pneumonia, bacteremia/septicemia, . Isolation of H. influenzae from a normally invasive disease meningitis, epiglottitis, pericarditis, osteomyelitis, septic arthritis, endocarditis and . sterile site (e.g., blood, cerebrospinal fluid 10590 [CSF], or less commonly, joint, pleural, or Confirmed: A case that is laboratory confirmed pericardial fluid), Probable: Meningitis with detection of H. influenzae type b antigen in cerebrospinal fluid OR (CSF). (Antigen test results in urine or serum are unreliable for diagnosis of H. . Detection of Haemophilus influenzae influenzae disease.) specific nucleic acid from a normally sterile site using a validated PCR assay See Normally Sterile Site Note: Serotyping of isolates can be performed at the DSHS laboratory. Serotyping is recommended for all H. influenzae cases and required by TAC on isolates from children under 5 years old. 30 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Hantavirus infection, non- Hantaviruses are rodent-borne viruses that can be transmitted to humans. Patients with . Detection of hantavirus-specific IgM* or HPS hantavirus infection typically present with nonspecific signs and symptoms including fever, rising titers of hantavirus-specific IgG, 11610 myalgia, headache, and chills. After the prodromal phase, symptoms of hantavirus OR pulmonary syndrome (HPS) may develop. . Detection of hantavirus-specific ribonucleic Hantavirus pulmonary acid sequence in clinical specimens, syndrome Non-HPS hantavirus infection is a febrile illness with non-specific signs and symptoms OR 11590 including fever, chills, myalgia, headache, and gastrointestinal symptoms, but no cardio- . Detection of hantavirus antigen by IHC in pulmonary symptoms. Clinical laboratory findings may include hemoconcentration, left shift in white blood cell count, neutrophilic leukocytosis, thrombocytopenia, and lung biopsy or autopsy tissues circulating immunoblasts. *Due to the high rate of false positives at HPS is an acute febrile illness characterized by non-specific viral symptoms including fever, commercial labs, a sample should be chills, myalgia, headache, and gastrointestinal symptoms, and one or more of the following forwarded to DSHS for confirmatory clinical features: testing . Bilateral diffuse interstitial edema, OR . Clinical diagnosis of acute respiratory distress syndrome (ARDS), OR . Radiographic evidence of noncardiogenic pulmonary edema, OR . Unexplained respiratory illness resulting in death, and includes autopsy examination demonstrating noncardiogenic pulmonary edema without an identifiable cause, OR . Healthcare record with a diagnosis of HPS OR . Death certificate that lists HPS as a cause of death or a significant condition contributing to death Confirmed: A clinically compatible case of HPS or non-HPS hantavirus infection with confirmatory laboratory results

31 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Hemolytic uremic syndrome, Hemolytic uremic syndrome (HUS) is characterized by the acute onset of microangiopathic The following are both present at some time post-diarrheal (HUS) hemolytic anemia, renal injury, and low platelet count. Thrombotic thrombocytopenic during the illness: 11550 purpura (TTP) also is characterized by these features but can include central nervous system . Anemia (acute onset) with microangiopathic (CNS) involvement and fever and can have a more gradual onset. Most cases of HUS (but changes (i.e., schistocytes, burr cells, or few cases of TTP) occur after an acute gastrointestinal illness (usually diarrheal). helmet cells) on peripheral blood smear, AND Confirmed: An acute illness diagnosed as HUS or TTP that both meets the laboratory . Renal injury (acute onset) evidenced by criteria and began within 3 weeks after onset of an episode of acute or bloody diarrhea either , proteinuria, or elevated Probable: creatinine level (i.e., greater than or equal to . An acute illness diagnosed as HUS or TTP that meets the laboratory criteria in a patient 1.0 mg/dL in a child aged less than 13 years who does not have a clear history of acute or bloody diarrhea in preceding 3 weeks, OR or greater than or equal to 1.5 mg/dL in a . An acute illness diagnosed as HUS or TTP, that a) has onset within 3 weeks after onset of person aged greater than or equal to 13 years, an acute or bloody diarrhea and b) meets the laboratory criteria except that or greater than or equal to 50% increase over baseline) microangiopathic changes are not confirmed Note: A low platelet count can usually, but not Note: See Shiga toxin-producing Escherichia coli (STEC) Cases meeting the criteria for both always, be detected early in the illness, but it conditions should be reported under each condition. can then become normal or even high. If a platelet count obtained within 7 days after onset of the acute gastrointestinal illness is not less than 150,000/mm3, other diagnoses should be considered.

Hepatitis A, acute An acute illness with a discrete onset of any sign or symptom consistent with acute viral . Immunoglobulin M antibody to hepatitis A 10110 hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal virus (anti-HAV IgM) positive, pain, or dark urine), AND a) either jaundice or elevated total bilirubin levels ≥ 3.0 OR mg/dL, OR elevated serum alanine aminotransferase (ALT) levels >200 IU/L, AND b) . Nucleic acid amplification test (NAAT; such the absence of a more likely diagnosis as Polymerase Chain Reaction [PCR] or Confirmed: genotyping) for hepatitis A virus RNA positive . A case that meets the clinical case criteria and is IgM anti-HAV positive, OR . A case that has hepatitis A virus RNA detected by NAAT (such as PCR or genotyping), OR . A case that meets the clinical criteria and occurs in a person who has an epidemiological link with a person who had contact (e.g., household or sexual) with a laboratory-confirmed hepatitis A case 15-50 days prior to the onset of symptoms. AND . A case that is not otherwise ruled out by IgM anti-HAV or NAAT for hepatitis A virus testing performed in a public health laboratory. Note: Hepatitis A is usually self-limiting and does not result in chronic infection. However, up to 10% of persons with hepatitis A may experience a relapse during the 6 months after acute illness. Cases of relapsing hepatitis A should not be enumerated as new cases. In addition, a case should not be counted as a hepatitis A case if there is an alternate, more likely diagnosis. 32 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Hepatitis B, acute An acute illness with a discrete onset of any sign or symptom* consistent with acute viral . Hepatitis B surface antigen (HBsAg) 10100 hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and positive, AND abdominal pain), AND either b) jaundice, or c) elevated serum alanine aminotransferase . IgM antibody to hepatitis B core antigen levels (ALT) >100 IU/L. (anti-HBc IgM) positive (if done) Confirmed: A case that meets the clinical case definition, is laboratory confirmed, and is not known to have chronic hepatitis B**

*A documented negative hepatitis B surface antigen (HBsAg) laboratory test result within 6 months prior to a positive test result (i.e., HBsAg, hepatitis B “e” antigen [HBeAg], or hepatitis B virus nucleic acid testing [HBV NAT] including genotype) does not require an acute clinical presentation to meet the surveillance case definition. **A person should be considered chronically infected if hepatitis B antigen tests (HBsAg, HBeAg, and/or nucleic acid tests) have been positive for 6 months or longer or if the patient has a history of chronic hepatitis B diagnosis.

Hepatitis B virus infection, Perinatal hepatitis B (HBV) in the newborn can range from asymptomatic to fulminant . Hepatitis B surface antigen (HBsAg) perinatal hepatitis. positive, hepatitis B e antigen (HBeAg) 10104 positive, or detectable Hepatitis B virus Confirmed: Child born in the US to a HBV-infected mother and positive for HBsAg at DNA (HBV DNA) ≥ 1 month of age and ≤ 24 months of age OR positive for HBeAg or HBV DNA ≥9 months of age and ≤ 24 months of age. Note: HBsAg must be tested more than 4 weeks after last dose of hepatitis B Probable: Child born in the US and positive for HBsAg at ≥ 1 month of age and ≤ 24 to be considered confirmatory. months of age OR positive for HBeAg or HBV DNA ≥9 months of age and ≤ 24 months of age, but whose mother’s hepatitis B status is unknown (i.e. epidemiologic linkage not present). Notes: . If the mother is known to be NOT infected with HBV, refer to the case definition for acute Hepatitis B. . These definitions are used for surveillance purposes only, not for perinatal hepatitis B prevention case management purposes.

33 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Hepatitis C, acute All hepatitis C virus cases in each classification category should be > 36 months of age, Hepatitis C virus detection test: 10101 unless known to have been exposed non-perinatally. . Nucleic acid test (NAT) or PCR test for Clinical Criteria: HCV RNA positive (including qualitative, . Jaundice, OR quantitative or genotype testing) . Peak total bilirubin levels >= 3.0 mg/DL, OR OR . Elevated serum alanine aminotransferase (ALT) level >200 IU/L, . A positive test indicating presence of AND hepatitis C viral antigen (HCV antigen)* . The absence of a more likely diagnosis (which may include evidence of acute liver *When and if a test for HCV antigen(s) is disease due to other causes or advanced due to pre-existing chronic approved by FDA and available Hepatitis C virus (HCV) infection or other causes, such as alcohol exposure, other viral hepatitis, hemochromatosis, etc.) Confirmed: . A case that meets the clinical criteria and is laboratory confirmed, OR . A documented negative HCV antibody followed within 12 months by a positive HCV antibody test (anti-HCV test conversion) in the absence of a more likely diagnosis, OR . A documented negative HCV antibody OR negative hepatitis C virus detection test (in someone without a prior diagnosis of HCV infection) followed within 12 months by a positive hepatitis C virus detection test (HCV RNA test conversion) in the absence of a more likely diagnosis. Probable: . A case that meets clinical criteria and has presumptive laboratory evidence (a positive anti-HCV antibody test), AND . Does not have a hepatitis C virus test reported, AND . Has no documentation of anti-HCV or HCV RNA test conversion within 12 months

34 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Hepatitis E, acute Typical clinical signs and symptoms of acute hepatitis E virus (HEV) are similar to those of . IgM anti-HEV from CDC laboratory or PCR 10103 other types of acute viral hepatitis and include abdominal pain anorexia, dark urine, fever, positive from reference laboratory hepatomegaly, jaundice, malaise, nausea, and vomiting. Other less common symptoms include arthralgia, diarrhea, pruritus, and urticarial rash. The period of infectivity following Note: No FDA approved tests to diagnose acute infection has not been determined but virus excretion in stools has been demonstrated HEV infection are available in the United up to 14 days after illness onset. In most hepatitis E outbreaks, the highest rates of clinically States. evident disease have been in young to middle-age adults; lower disease rates in younger age groups can be the result of anicteric and/or subclinical HEV infection. No evidence of chronic infection has been detected in long-term follow-up of patients with hepatitis E. The case fatality rate is low except in pregnant women where it can reach 20% among those infected during the third trimester of pregnancy. Confirmed: A case that meets the clinical case description and is laboratory confirmed Probable: A case that meets the clinical case description with supportive laboratory evidence (positive IgM antibody from labs other than CDC), OR negative tests for other acute hepatitis markers and an epidemiological link to other confirmed cases or travel history to an endemic area during exposure period

Hookworm (ancylostomiasis) A parasitic infection caused by the soil-transmitted helminths Necator americanus and . Microscopic identification of Ancylostoma 80760 Ancylostoma duodenale (rarely by other Ancylostoma species, e.g. A.ceylanicum). Itching or Necator (Hookworm) eggs in feces, and localized rash are often the first signs of infection. Other symptoms may include cough, OR abdominal discomfort, diarrhea, blood in the stool, loss of appetite, nausea, fatigue, or . Microscopic identification of Ancylostoma pale skin. Light hookworm infections generally produce few or no clinical effects. In heavy or Necator species larvae cultured from the infections, blood loss at the site of the intestinal attachment of adult worms leads to iron feces, deficiency anemia. In rare cases, prolonged, severe anemia can result in congestive heart OR failure and death. Children with heavy long-term infection may have impaired growth and . Identification of Ancylostoma or Necator delayed mental development. species adult worms expelled after treatment treatment or removed during endoscopy Confirmed: A case that is laboratory confirmed

35 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Influenza, human isolates - The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to . Influenza virus isolation in tissue cell culture [outbreaks only] severe illness and at times can lead to death. Symptoms of flu may include fever, headache, from respiratory specimens, 11060 extreme tiredness, dry cough, sore throat, runny or stuffy nose, and muscle aches. Stomach OR symptoms (nausea, vomiting, and diarrhea) can occur but are more common in children than . Reverse-transcriptase polymerase chain adults. Complications of flu can include bacterial pneumonia, ear infections, sinus infections, reaction (RT-PCR) testing of respiratory , and worsening of chronic medical conditions, such as congestive heart failure, specimens, asthma, or diabetes. OR . Immunofluorescent antibody staining (direct Confirmed: Case that is clinically compatible and laboratory confirmed or indirect) of respiratory specimens, Note: Influenza is not a reportable condition in Texas. See Influenza A, novel/variant OR infection for reporting of novel/variant strains. See Influenza-associated pediatric mortality . Rapid influenza diagnostic testing of for reporting of influenza-associated deaths in all persons aged <18 years. respiratory specimens, OR . Immunohistochemical (IHC) staining for influenza viral antigens in respiratory tract tissue from autopsy specimens, OR . Four-fold rise in influenza hemagglutination inhibition (HI) antibody titer in paired acute and convalescent sera

36 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Influenza A, novel/variant An illness compatible with influenza virus infection (fever >100 degrees Fahrenheit, with Identification of an influenza A virus subtype 11062 cough and/or sore throat) or strain that is different from currently Confirmed: A case of human infection with a laboratory confirmed novel/variant influenza circulating human influenza H1 and H3 strains A virus as confirmed by CDC’s influenza laboratory, by public health laboratories using CDC- Probable: A case meeting the clinical criteria and epidemiologically linked* to a confirmed approved protocols for that specific strain, or case, but for which no confirmatory laboratory testing for novel/variant influenza virus by labs using FDA-authorized tests for specific infection has been performed or test results are inconclusive for a novel/variant influenza A strains. virus infection . Novel/variant subtypes include, but are not Epidemiologic linkage criteria: a) the patient has had contact with one or more persons who limited to, H2, H5, H7, and H9 subtypes. either have or had the disease and b) transmission of the agent by the usual modes of . Influenza H1 and H3 subtypes originating transmission is plausible. A case can be considered epidemiologically linked to a laboratory- from a non-human species or from genetic confirmed case if at least one case in the chain of transmission is laboratory confirmed. re-assortment between animal and human viruses are also novel/variant subtypes or Suspect: A case meeting the clinical criteria in which influenza A has been detected but is strains. pending laboratory confirmation. Any case of human infection with an influenza A virus that is different from currently circulating human influenza H1 and H3 viruses is classified as a . Methods available for detection of currently suspect case until the confirmation process is complete. circulating human influenza viruses at public health laboratories (e.g., rRT-PCR) will also Note: Typically, sporadic novel/variant influenza cases will have a history of either close detect suspected novel/variant subtypes and contact with ill animals known to transmit novel subtypes of influenza A (such as wild strains. or poultry, swine, or other mammals) OR travel, within 14 days, to any country where a . Initial confirmation that a specific influenza novel influenza A virus (such as highly pathogenic avian influenza A H5N1) has been A virus represents a novel/variant virus will recently identified in animals or people. be performed by CDC’s influenza laboratory. . Currently, only viral isolation, RT-PCR, gene sequencing, or a 4-fold rise in strain- specific serum antibody titers are considered confirmatory for case classification purposes.

37 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Influenza-associated An influenza-associated death is defined for surveillance purposes as a death resulting from a Laboratory testing for influenza virus infection pediatric mortality clinically compatible illness that was confirmed to be influenza by an appropriate laboratory can be done on pre- or post-mortem clinical 11061 or rapid diagnostic test. There should be no period of complete recovery between the illness specimens, and may include identification of and death. Influenza-associated deaths in all persons aged <18 years should be reported. influenza A or B virus infections by a positive result by at least one of the following: A death should not be reported if there is no laboratory confirmation of influenza virus . Influenza virus isolation in tissue cell culture infection, the influenza illness is followed by full recovery to baseline health status prior to from respiratory specimens, death, the death occurs in a person 18 years of age or older, or after review and consultation OR there is an alternative agreed upon cause of death which is unrelated to an infectious process . Reverse-transcriptase polymerase chain (For example, a child with a positive influenza test whose death clearly resulted from trauma reaction (RT-PCR) testing of respiratory after a car accident would not qualify as a case. However, a child with a respiratory illness specimens, and a positive influenza test whose death is attributed to another infectious cause such as OR staphylococcal pneumonia would still qualify as a case.). . Immunofluorescent antibody staining (direct Confirmed: A death meeting the clinical case definition that is laboratory confirmed or indirect) of respiratory specimens, OR

. Rapid influenza diagnostic testing of respiratory specimens, OR . Immunohistochemical (IHC) staining for influenza viral antigens in respiratory tract tissue from autopsy specimens, OR . Four-fold rise in influenza hemagglutination inhibition (HI) antibody titer in paired acute and convalescent sera

38 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Legionellosis Legionellosis is associated with three clinically and epidemiologically distinct illnesses: . Isolation (culture) of any Legionella 10490 Legionnaires’ disease, which is characterized by fever, myalgia, cough, and clinical or organism from respiratory , lung radiological pneumonia; , a milder illness without pneumonia; and tissue, pleural fluid, or other normally extrapulmonary legionellosis, a rare manifestation in which Legionella can cause disease at sterile fluid, sites outside the lungs (e.g., endocarditis, wound infection, joint infection, graft infection). OR . Detection of any Legionella species from Confirmed: A clinically compatible case that meets at least one of the confirmatory lower respiratory secretions, lung tissue, or laboratory criteria pleural fluid by a validated nucleic acid Probable: A clinically compatible case with an epidemiologic linkage* during the incubation amplification test (e.g. PCR), period OR *Epidemiologic linkage criteria: . Detection of 1) Linkage to a setting with a confirmed source of Legionella serogroup 1 antigen in urine using validated reagents, OR OR 2) Linkage to a setting with a suspected source of Legionella that is associated with . Demonstration of seroconversion by a at least one confirmed case fourfold or greater rise in specific serum antibody titer between paired acute and convalescent phase serum specimens to Legionella pneumophila serogroup 1 using validated reagents

Leishmaniasis Leishmaniasis is a polymorphic protozoan disease of skin and mucous membranes. The . Microscopic identification of the nonmotile, 80550 disease starts with a macule then a papule that enlarges and typically becomes an indolent intracellular form (amastigote) in stained ulcer in the absence of bacterial infection. Lesions can be single or multiple, occasionally specimens from lesions, nonulcerative and diffuse. Lesions can heal spontaneously within weeks to months, or last OR for a year or more. In some individuals, certain Leishmania strains can disseminate to cause . Culture of the motile, extracellular form mucosal lesions (espundia) even years after the primary cutaneous lesion has healed. These (promastigote) on suitable media, sequelae, which involve nasopharyngeal tissues, are characterized by progressive tissue OR destruction and often scanty presence of parasites, and can be severely disfiguring. . An intradermal (Montenegro) test with Recurrence of cutaneous lesions after apparent cure can occur as ulcers, papules, or nodules leishmanin, an antigen derived from the at or near the healed original ulcer. Mode of transmission to humans is through the bite of promastigotes, is usually positive in infected female phlebotomine sandflies. established disease, OR Confirmed: A clinically compatible case that is laboratory confirmed . Positive Leishmania Real-Time PCR or Leishmania PCR and DNA sequencing at CDC

39 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Listeriosis In adults, invasive disease caused by manifests most commonly as . Isolation of L. monocytogenes from a 10640 meningitis or bacteremia; infection during pregnancy can result in fetal loss through normally sterile site, e.g., blood, miscarriage or stillbirth, or neonatal meningitis or bacteremia. Other manifestations can also cerebrospinal fluid (CSF), or less commonly, be observed. joint, pleural, or pericardial fluid, OR Confirmed: A clinically compatible case that is laboratory confirmed . Isolation of L. monocytogenes from products Probable: The mother of a neonate with confirmed or probable listeriosis, even if the of conception at time of delivery and non- laboratory criteria are not met for the mother; a neonate born to a mother with confirmed or sterile sites of neonates obtained with 48 probable listeriosis, even if laboratory criteria are not met for the neonate; or a clinically hours of delivery, compatible case detected through use of a culture independent laboratory testing method. OR . In the setting of miscarriage or stillbirth, Suspect: Isolation of L. monocytogenes from a non-invasive clinical specimen, e.g., stool, isolation of L. monocytogenes from placental urine, wound. or fetal tissue, Notes: OR . Pregnancy loss and intrauterine fetal demise are considered maternal outcomes and . In the setting of pregnancy or live birth, would be counted as a single case in the mother. isolation of L. monocytogenes from mother’s . Cases in neonates and mothers should be reported separately when each meets the case or neonate’s blood or other sterile site, or definition. A case in a neonate is counted if live-born. from placental or amniotic fluid . A case should not be counted as a new case if laboratory results were reported within 365 See Normally Sterile Site days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection. Note: As required by TAC all Listeria monocytogenes isolates must be submitted to the DSHS Laboratory.

40 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Lyme disease A systemic, tickborne disease with protean manifestations, including dermatologic, . Positive culture for B. burgdorferi, 11080 rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease OR is the initial skin lesion, (EM). For most patients, the expanding EM . IgG1 immunoblot seropositivity using lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, established criteria mildly stiff neck, arthralgia, or myalgia. OR 2 Confirmed: A case with physician-diagnosed EM ≥ 5 cm in size with an exposure in a high- . IgM immunoblot seropositivity using incidence state or country*, OR a case of physician-diagnosed EM ≥ 5 cm in size with established criteria with laboratory confirmation with an exposure in a low-incidence state or country*, OR a case . Positive/Equivocal EIA or IFA test, with at least one late manifestation** that has laboratory confirmation. AND . Specimen collected ≤ 30 days after *Exposure is defined as having been (≤ 30 days before onset of EM) in wooded, brushy, or symptom onset grassy areas (i.e., potential tick habitats). An exposure in a high-incidence state is defined as exposure in a state with an average Lyme disease incidence of at least 10 confirmed ¹IgG WB is considered positive when at least cases/100,000 for the previous three reporting years. A low-incidence state is defined as a state five of the following 10 bands are present: 18 with disease incidence of <10 confirmed cases/100,000 kDa, 24 kDa (OspC)*, 28 kDa, 30 kDa, 39 (http://www.cdc.gov/lyme/stats/tables.html). Texas is considered a low-incidence state for kDa (BmpA), 41 kDa flagellin (Fla), 45 kDa, Lyme disease. 58 kDa (not GroEL), 66 kDa, and 93 kDa. **For purposes of surveillance, late manifestations include any of the following when an Note: While a single IgG WB is adequate for alternate explanation is not found: surveillance purposes, a two-tier test is still . Musculoskeletal system: recurrent, brief attacks (weeks or months) of objective joint recommended for patient diagnosis. swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. ²IgM WB is considered positive when at . Nervous system: any of the following, alone or in combination: lymphocytic meningitis; least two of the following three bands are cranial neuritis, particularly facial palsy (can be bilateral); radiculoneuropathy; or, rarely, present: 24 kilodalton (kDa) outer surface encephalomyelitis. protein C (OspC)*, 39 kDa basic membrane . Cardiovascular system: acute onset of high-grade (2nd or 3rd-degree) atrioventricular protein A (BmpA), and 41 kDa (Fla). conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Note: Disregard IgM results for specimens collected >30 days after symptom onset. Probable: Any other clinically compatible case of physician-diagnosed Lyme disease that has laboratory confirmation and the absence of a more likely clinical explanation. *Depending upon the assay, OspC could be indicated by a band of 21, 22, 23, 24 or 25 Suspect: A case of EM with no known exposure and no laboratory evidence of infection, OR kDA. a case with laboratory evidence of infection, but no clinical information available Notes: . Lyme disease reports will not be considered cases if the medical provider specifically states this is not a case of Lyme disease, or the only symptom listed is “tick bite” or “insect bite.” . A case should not be counted as new if the case has ever previously been reported for the same condition.

41 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Malaria Initial symptoms of malaria are non-specific and include fever, chills, sweats, headaches, . Detection and specific identification of 10130 muscle pains, nausea and vomiting. In severe cases of malaria (usually caused by malaria parasite species by microscopy on Plasmodium falciparum), clinical findings can also include confusion, coma, neurologic blood films in a laboratory with focal signs, severe anemia, and respiratory difficulties. appropriate expertise Confirmed: A case that is laboratory confirmed in any person (symptomatic or OR asymptomatic) diagnosed in the United States, regardless of whether the person . Detection of Plasmodium species by experienced previous episodes of malaria while outside the country nucleic acid test* OR Suspect: Detection of Plasmodium species by rapid diagnostic antigen testing (RDT) without . Detection of unspeciated malaria parasite confirmation by microscopy or nucleic acid testing in any person (symptomatic or by microscopy on blood films in a asymptomatic) diagnosed in the United States, regardless of whether the person experienced laboratory with appropriate expertise previous episodes of malaria while outside the country * Laboratory-developed malaria PCR tests Note: A subsequent attack experienced by the same person but caused by a different must fulfill CLIA requirements, including Plasmodium species is counted as an additional case. A subsequent attack experienced by validation studies. the same person and caused by the same species in the U.S. may indicate a relapsing infection or treatment failure caused by drug resistance.

Measles (Rubeola) An illness characterized by all of the following: a generalized maculopapular rash lasting at . IgG seroconversion or a significant rise in 10140 least 3 days; a temperature ≥ 101.0o F (>38.3 o C); and cough, coryza, or conjunctivitis. measles immunoglobulin G antibody level by any standard serologic assay *, Confirmed: OR An acute febrile rash illness (temperature can be lower than 101 o and rash < 3 days) that is: . Isolation of measles virus from a clinical . Laboratory confirmed, OR specimen*, . Epidemiologically linked to a laboratory confirmed measles case OR . Detection of measles-virus-specific nucleic acid by PCR *, OR . A positive serological test for measles immunoglobulin M antibody* not otherwise ruled out by other confirmatory testing or more specific measles testing in a public health laboratory *Not explained by MMR vaccination during the previous 6-45 days

42 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Meningococcal infection, Invasive manifests most commonly as meningitis and/or . Isolation of Neisseria meningitidis from a invasive (Neisseria meningococcemia that can progress rapidly to purpura fulminans, shock, and death. normally sterile site, meningitidis) However, other manifestations (e.g., pneumonia, myocarditis, endocarditis or pericarditis, OR 10150 arthritis, cervicitis) might be observed. . Isolation of N. meningitidis from purpuric Confirmed: A case that is laboratory confirmed lesions, OR Probable: A case that has one of the following: . Detection of N. meningitidis-specific nucleic . N. meningitidis antigen detection by immunohistochemistry (IHC) on formalin-fixed tissue acid in a specimen obtained from a normally . N. meningitidis antigen detection by latex agglutination of CSF sterile site, using a validated polymerase Suspect: A case that has one of the following: chain reason (PCR) assay . Clinical purpura fulminans in the absence of a positive See Normally Sterile Site . Gram-negative diplococci, not yet identified, isolated from a normally sterile site (e.g., blood or CSF) Note: As required by TAC all Neisseria meningitidis isolates from normally sterile sites and/or purpuric lesions must be submitted to the DSHS Laboratory for typing and molecular analysis.

43 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Multidrug-resistant Multidrug-resistant Acinetobacter (MDR-A) are strictly aerobic gram-negative Any Acinetobacter species that is non- Acinetobacter (MDR-A) coccobacilli of the Moraxellaceae family and have more than 25 species within the susceptible (i.e., resistant or intermediate) 40684 genus. Acinetobacter have an intrinsic resistance factor that enables them to to at least 1 antibiotic in at least 3 of the hydrolyze carbapenem antibiotics, causing resistance to and , following 6 antimicrobial classes: and may produce additional resistance to other classes of antibiotics. 1. βeta-Lactam (Piperacillin, Piperacillin/Tazobactam) Healthcare-associated Acinetobacter respiratory tract infections (including ventilator- 2. Aminoglycosides (Amikacin, associated pneumonia), catheter-related urinary tract infections, bloodstream infections, Gentamicin, Tobramycin) and wound infections have all been well documented in medical literature. In addition, 3. Carbapenems (Imipenem, Meropenem, Acinetobacter has been related but not limited to other types of infection such as Doripenem) meningitis, endocarditis, and osteomyelitis. Symptoms associated with MDR-A infections 4. Fluoroquinolones (, generally vary based on the infected site. MDR-A can colonize or infect any body site. Levofloxacin) Confirmed: Acinetobacter species from any body site that is laboratory confirmed. 5. (Cefepime, ) Additional information on MDR-A can be found at: 6. Sulbactam (/Sulbactam) https://cdc.gov/hai/organisms/acinetobacter.html Only the above antibiotics can meet the case definition. Note: There is no requirement to submit isolates to the DSHS Laboratory. Please contact a DSHS HAI Epidemiologist or the DSHS Laboratory for additional information on available laboratory support. If the MDR- A isolate is sent to the DSHS Lab for additional testing, use the submitting lab’s antibiotic susceptibility testing results to meet the epi case criteria.

Multidrug-resistant See specific organism for definition (ie: CRE, MDR-A , VISA , VRSA ) organisms (MDRO) (See specific organism for definition)

44 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Mumps Acute parotitis or other salivary gland swelling lasting at least 2 days, or orchitis or . Isolation of mumps virus from a clinical 10180 oophoritis unexplained by another more likely diagnosis specimen, OR Confirmed: A case that has a positive mumps PCR result, OR positive mumps culture, . Detection of mumps-virus-specific nucleic AND either meets the clinical case definition, OR has aseptic meningitis, encephalitis, acid by PCR hearing loss, mastitis, or pancreatitis Note: An elevated serum amylase is not Probable: A case that meets the clinical case definition, AND confirmatory for mumps. . Has a positive test for serum anti-mumps immunoglobulin M (IgM) antibody, OR . Has an epidemiologic link to another probable or confirmed case or linkage to a group/community defined by public health during an outbreak of mumps Suspect: A case that has parotitis, acute salivary gland swelling, orchitis, or oophoritis unexplained by another more likely diagnosis, OR a has a positive lab result with no mumps clinical symptoms (with or without an epidemiologic link to a confirmed or probable case).

Norovirus - [outbreaks Norovirus infection usually presents as acute-onset vomiting, watery non-bloody diarrhea . Polymerase chain reaction (PCR) can be only] with abdominal cramps, and nausea. Low-grade fever also occasionally occurs, and vomiting used to test stool and emesis samples, as well 10996 is more common in children. Dehydration is the most common , especially as environmental swabs in special studies. among the young and elderly, and can require medical attention. Symptoms usually last 24 to (Identification of norovirus can best be made 60 hours. Recovery is usually complete and there is no evidence of any serious long-term from stool specimens taken within 48 to 72 sequelae. Studies with volunteers given stool filtrates have shown that asymptomatic hours after onset of symptoms. Virus can infection can occur in as many as 30% of infections, although the role of asymptomatic sometimes be found in stool samples taken infection in norovirus transmission is not well understood. as late as 2 weeks after recovery.) OR Confirmed: A clinically compatible case that is laboratory confirmed . Detection of norovirus by direct and immune Probable: Norovirus can be established as the probable cause of an outbreak if: electron microscopy of fecal specimens, . The mean (or median) illness duration is 12 to 60 hours, AND OR . The mean (or median) incubation period is 24 to 48 hours, AND . Fourfold increase of norovirus antibodies in . More than 50% of people have vomiting, AND acute- and convalescent-phase blood . No bacterial agent is found samples Note: The etiology of GI outbreaks should be confirmed by submitting specimens to the DSHS Laboratory. Sequencing of norovirus strains found in clinical and environmental samples has greatly helped in conducting epidemiologic investigations.

45 Revision date: January – October 2020

Novel Coronavirus 2019 A novel coronavirus is a new coronavirus that has not been previously identified. The . Detection of SARS-CoV-2 RNA in a clinical (January through May 19, virus causing coronavirus disease first identified in Wuhan, China in 2019 (COVID-19), specimen using a molecular amplification 2020) is not the same as coronaviruses that commonly circulate among humans and cause mild detection test 11065 illness, like the common cold. Symptoms of COVID-19 may include fever, cough, shortness of breath, pneumonia, or acute respiratory distress syndrome (ARDS).

Symptoms of COVID-19 are non-specific and the disease presentation can range from no symptoms (asymptomatic) to severe pneumonia and death. COVID-19 is a mild to moderate illness for approximately 80% of individuals evaluated with the disease; 15% are severe infection requiring supplemental oxygen; and 5% are critical infections requiring mechanical ventilation. People with COVID-19 generally develop signs and symptoms, including mild respiratory symptoms and fever ~5 days after infection (mean incubation period 5-6 days, range 1-14 days). Clinical criteria: . At least two of the following symptoms: Fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s); OR . At least one of the following symptoms: cough, shortness of breath, or difficulty breathing; OR . Severe respiratory illness with at least one of the following: Clinical or radiographic evidence of pneumonia, or Acute respiratory distress syndrome (ARDS) AND . No alternative more likely diagnosis. Confirmed: A case that is laboratory confirmed. Probable: A person who meets the criteria for a suspect case, has absent or inconclusive* laboratory results for novel coronavirus infection, and is a close contact** of a laboratory confirmed case. Suspect: A person who meets the clinical criteria AND at least one of the following: 1) Has recent travel history to any country where a novel coronavirus has been recently identified in people 2) Has had close contact** with a symptomatic person who recently traveled to any country where a novel coronavirus has been recently identified in people 3) Is a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which a novel coronavirus is being evaluated, in consultation with state and local health departments 4) Has a recent history of other relevant exposures, as defined by CDC *Examples of laboratory results that may be considered inconclusive include a positive test on a single PCR target, a positive test with an assay that has limited performance data available, or a negative test on an inadequate specimen. **See https://emergency.cdc.gov/han/2020/han00429.asp for current CDC Patient Under Investigation (PUI) criteria for suspect cases and for the definition of “close contact”.

46 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Novel Coronavirus 2019 A novel coronavirus is a newly identified coronavirus that has not been previously . Laboratory evidence using a method (May 20, 2020 – October identified in the human population and it is assumed there is no existing immunity to the approved or authorized by the FDA or 2020) virus. The virus (SARS-CoV-2) causing 2019 novel coronavirus disease (COVID-19), designated authority: 11065 first identified in Wuhan, China in 2019 is not the same as coronaviruses that commonly circulate among humans and cause mild illness, like the common cold. Symptoms of COVID-19 are non-specific and the disease presentation can range from no symptoms . Detection of SARS-CoV-2 RNA in a (asymptomatic) to severe pneumonia and death. People with COVID-19 generally clinical specimen using a molecular develop signs and symptoms, including mild respiratory symptoms and fever ~5 days amplification detection test after infection (mean incubation period 5-6 days, range 1-14 days). Confirmed: A case that is laboratory confirmed Probable: A case that: . Meets clinical criteria AND epidemiologic linkage criteria with no confirmatory laboratory testing performed for COVID-19, OR . Using a method approved or authorized by the FDA or designated authority, meets presumptive laboratory evidence of o Detection of specific antigen (Ag) in a clinical specimen, OR o Detection of a specific antibody in serum, plasma, or whole blood indicative of a new or recent infection . AND meets either clinical criteria OR epidemiologic linkage criteria. OR . Meets vital records criteria (death certificate lists COVID-19 disease or SARS- CoV-2 as a cause of death or a significant condition contributing to death) with no confirmatory laboratory testing performed for COVID-19. Clinical criteria: . At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s); OR . At least one of the following symptoms: cough, shortness of breath, or difficulty breathing; OR . Severe respiratory illness with at least one of the following: o Clinical or radiographic evidence of pneumonia, or o Acute respiratory distress syndrome (ARDS) AND . No alternative more likely diagnosis Epidemiologic linkage criteria: One or more of the following exposures in the last 14 days before onset of symptoms: . Close contact* with a confirmed or probable case of COVID-19 disease . Close contact* with a person with clinically compatible illness AND linkage to a confirmed case of COVID-19 disease. . Travel to or residence in an area with sustained, ongoing community transmission of SARS-CoV-2. 47 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

. Member of a risk cohort as defined by public health authorities during an outbreak (ex. symptomatic residents of a nursing home where at least one laboratory confirmed COVID-19 case has been identified). *Close contact is defined as being within 6 feet for at least a period of 10 minutes to 30 minutes or more depending upon the exposure. In healthcare settings, this may be defined as exposures of greater than a few minutes or more. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact.

Novel Coronavirus 2019 A novel coronavirus is a newly identified coronavirus that has not been previously . Detection of SARS-CoV-2 RNA in a (November 2020) identified in the human population and it is assumed there is no existing immunity to clinical or autopsy specimen using a 11065 the virus. The virus (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19), molecular amplification detection test first identified in Wuhan, China in 2019 is not the same as coronaviruses that commonly circulate among humans and cause mild illness, like the common cold. Symptoms of COVID-19 are non-specific and the disease presentation can range from no symptoms (asymptomatic) to severe pneumonia and death. People with COVID-19 generally develop signs and symptoms, including mild respiratory symptoms and fever ~5 days after infection (mean incubation period 5-6 days, range 1-14 days). Confirmed: A case that is laboratory confirmed* Probable: A case that: . Meets clinical criteria AND epidemiologic linkage criteria with no confirmatory laboratory testing performed for SARS-CoV-2, OR . Meets presumptive laboratory evidence* (detection of SARS-CoV-2 by antigen test in a respiratory specimen) OR . Meets vital records criteria (death certificate lists COVID-19 disease or SARS-CoV-2 as an underlying cause of death or a significant condition contributing to death) with no confirmatory laboratory testing performed for SARS-CoV-2. Suspect: A case that: . Meets supportive laboratory evidence* of: o Detection of specific antibody in serum, plasma, or whole blood, OR o Detection of specific antigen by immunocytochemistry in an autopsy specimen . AND has no prior history of being a confirmed or probable case *LABORATORY EVIDENCE USING A METHOD APPROVED OR AUTHORIZED BY THE FDA OR DESIGNATED AUTHORITY

Clinical Criteria: . At least two of the following symptoms: fever (measured or subjective),

48 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

chills, rigors, myalgia, headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose; OR . At least one of the following symptoms: cough, shortness of breath, difficulty breathing, new olfactory disorder, new taste disorder; OR . Severe respiratory illness with at least one of the following: clinical or radiographic evidence of pneumonia, or acute respiratory distress syndrome (ARDS) AND . No alternative more likely diagnosis

Epidemiologic linkage criteria: One or more of the following exposures in the prior 14 days: . Close contact** with a confirmed or probable case of COVID-19 disease . Member of a risk cohort as defined by public health authorities during an outbreak (ex. symptomatic residents of a nursing home where at least one laboratory confirmed COVID-19 case has been identified).

**Close contact is generally defined as being within 6 feet for at least 15 minutes. However, it depends on the exposure level and setting; for example, in the setting of an aerosol-generating procedure in healthcare settings without proper personal protective equipment (PPE), this may be defined as any duration. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact.

Outbreaks, exotic diseases, In addition to specified reportable conditions, any outbreak, exotic disease, or unusual and unusual expression of group expression of disease that may be of public health concern should be reported by disease the most expeditious means available. Influenza, human isolates 11060 Norovirus 10996 Streptococcal toxic- shock syndrome 11700

49 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Paragonimiasis Paragonimiasis (lung fluke trematode) is transmitted by eating inadequately cooked . Microscopic identification of Paragonimus 80664 crustaceans (primarily crayfish in the US) that are infected with the parasite. Disease eggs in feces, sputum, pleural fluid, CSF, or most frequently involves the lungs. Initial signs and symptoms may be diarrhea and , abdominal pain followed several days later by fever, chest pain, and fatigue. The OR symptoms may also include a dry cough, which later becomes productive with rusty- . Identification of worms or eggs in biopsies colored or blood-tinged sputum on exertion, and pleuritic chest pain. X-ray findings of pulmonary, cerebral, subcutaneous, or may include diffuse and/or segmental infiltrates, nodules, cavities, ring cysts and/or intra-abdominal nodules or cystic lesions pleural effusions. Extrapulmonary disease is not uncommon, with flukes found in such sites as the CNS, subcutaneous tissues, intestinal wall, peritoneal cavity, liver, lymph nodes and genitourinary tract. Infection usually lasts for years, and the infected person may be asymptomatic. Paragonimiasis may be mistaken for , clinically and on chest X-rays. Confirmed: A case that is laboratory confirmed Probable: A clinically compatible case with . Detection of Paragonimus antibodies by CF, EIA, or immunoblot, or . Positive skin test for Paragonimus, or . History of ingestion of inadequately cooked crustaceans and marked eosinophilia with total WBC count in the normal range or supportive x-ray findings

Pertussis A cough illness lasting at least 14 days AND at least one of the following additional . Isolation (culture) of 10190 symptoms in the absence of a more likely diagnosis: from a clinical specimen, . Paroxysmal coughing, OR OR . Inspiratory "whoop," OR . Positive polymerase chain reaction (PCR) . Post-tussive vomiting, OR assay for Bordetella pertussis . Apnea (with or without cyanosis) Note: Because B. pertussis can be difficult to Confirmed: A person with an acute cough illness of any duration who is laboratory culture, a negative culture result does not rule confirmed out pertussis. Negative PCR results do not Probable: In the absence of a more likely diagnosis, a person who is not laboratory require investigation unless reported as a confirmed (not tested, tests are negative, or tested by serology or DFA), and is either: suspected case by a healthcare provider. Direct . A person with an acute cough illness of any duration, with fluorescent antibody (DFA) staining of a  At least one of the following signs or symptoms: patient’s specimen and serological laboratory . Paroxysms of coughing, OR results (pertussis IgA, IgG or IgM) are NOT . Inspiratory whoop, OR considered confirmatory for pertussis, but . Post-tussive vomiting, OR should be investigated as soon as possible. . Apnea (with or without cyanosis) AND epidemiological linkage to a laboratory confirmed case OR . A person who meets the clinical case definition.

50 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Plague Plague, a bacterial infection caused by , is transmitted to humans via flea bites . Isolation of Y. pestis from a clinical 10440 or by direct exposure to infected tissues or respiratory droplets. The disease is characterized specimen with culture identification by fever, chills, headache, malaise, prostration, and leukocytosis and can manifest in one or validated by a secondary assay (e.g. more specific clinical presentations which typically reflect the route of exposure to the lysis assay, DFA assay) as pathogen. performed by a CDC or LRN laboratory, OR Clinical evidence: Acute onset of fever as reported by the patient or healthcare provider with . Four-fold or greater change in paired serum or without one or more of the following: regional lymphadenitis, septicemia, pneumonia, or antibody titer to Y. pestis F1 antigen pharyngitis with cervical lymphadenitis. For isolates of other species of Yersinia, see Confirmed: A clinically compatible case with confirmatory laboratory evidence, OR a Yersiniosis clinically compatible case with presumptive laboratory evidence AND epidemiologic linkage (see below) Note: As required by TAC, all Y. pestis isolates must be submitted to an LRN laboratory. Probable: A clinically compatible case with a presumptive laboratory evidence* as listed below that lacks an alternative diagnosis and epidemiologic linkage (see below) . Elevated serum antibody titer(s) to Y. pestis fraction 1 (F1) antigen (without documented four-fold or greater change) in a patient with no history of plague vaccination, OR . Detection of Y. pestis specific DNA or antigens, including F1 antigen, in a clinical specimen by DFA, IHC, or PCR Suspect: A clinically compatible case without laboratory evidence that has an epidemiologic linkage OR an individual with confirmed or presumptive laboratory evidence without any associated clinical information Epidemiologic linkage is defined as one or more of the following: . Person that is epidemiologically linked to a person or animals with confirmatory laboratory evidence within the prior two weeks; OR . Close contact with a confirmed pneumonic plague case, including but not limited to presence within two meters of a person with active cough due to pneumonic plague; OR . A person that lives in or has traveled within two weeks of illness onset to a geographically-localized area with confirmed plague epizootic activity in or animals as determined by the relevant local authorities. *Other laboratory tests, including rapid bedside tests, are in use in some low resourced international settings but are not recommended as laboratory evidence of plague infection in the United States.

51 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Poliomyelitis, paralytic Acute onset of a flaccid paralysis of one or more limbs with decreased or absent tendon . Isolation of poliovirus type 1, 2, or 3 from a 10410 reflexes in the affected limbs, without other apparent cause, and without sensory or clinical specimen (stool or CSF) cognitive loss Confirmed*: A case that meets the clinical case definition in which the patient has a neurological deficit 60 days after onset of initial symptoms, has died, or has unknown follow-up status Probable*: A case that meets the clinical case definition *Note: All suspected cases of paralytic poliomyelitis are reviewed by a panel of expert consultants at the Centers for Disease Control and Prevention (CDC) before final case classification occurs.

Poliovirus infection, Most poliovirus infections are asymptomatic or cause mild febrile disease. . Poliovirus isolate identified in an appropriate nonparalytic clinical specimen, with confirmatory typing Confirmed: Laboratory confirmed poliovirus infection in a person without symptoms of 10405 and sequencing performed by the CDC paralytic poliomyelitis Poliovirus Laboratory

Primary amebic See Amebic meningoencephalitis (PAM) meningoencephalitis (PAM)

52 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Prion diseases such as Creutzfeldt-Jakob disease (CJD) is a human prion disease described as rapidly Confirmatory Laboratory Criteria - Creutzfeldt-Jakob disease progressive, invariably fatal, and neurodegenerative. Human prion diseases include sporadic, genetic, & iatrogenic CJD (CJD) sporadic forms of disease (sporadic CJD, sporadic Fatal Insomnia, and Variably . Diagnosis by standard neuropathological 80060 Protease-Sensitive Prionopathy), genetic or familial forms of disease (familial CJD, techniques Familial Fatal Insomnia, and Gerstmann-Sträussler-Scheinker disease) and acquired AND/OR (continued on next page) forms of disease (iatrogenic CJD, Kuru (described only in the Fore population of Papua . Immunohistocytochemistry New Guinea), and variant CJD).Classical sporadic CJD presentation consists of rapidly AND/OR progressive dementia, visual abnormalities, myoclonus, or cerebellar dysfunction (where . Western blot both balance abnormalities and muscle incoordination are seen which commonly present AND/OR as gait, speech, and swallowing disorders). Most patients eventually develop pyramidal . Presence of scrapie-associated fibrils and extrapyramidal dysfunction such as abnormal reflexes (hyperreflexia), spasticity, tremors, and rigidity. Akinetic mutism appears late in the disease. Median duration of Supportive Laboratory Criteria - illness is 4 months; the duration of illness rarely exceeds 12 months. sporadic, genetic, & iatrogenic CJD For purposes of surveillance, for prion diseases such as CJD notification also includes . CSF 14-3-3 protein: Reported as elevated, sporadic fatal insomnia (sFI), Variably Protease-Sensitive Prionopathy (VPSPr), fatal above normal limits, or positive. If 14-3-3 familial insomnia (FFI), Gerstmann-Sträussler-Scheinker (GSS) disease, Kuru, and any protein is the only supportive test used in novel prion disease affecting humans. determining classification, then duration of illness must be < 2 years. Sporadic CJD (sCJD) . RT-QuIC: Positive . EEG: Reported as “typical of” or Confirmed: Satisfactory confirmatory test findings on autopsy or biopsy of brain tissue “consistent with” sporadic CJD or the Probable: report indicates the presence of . Neuropsychiatric disorder AND positive RT-QuIC in CSF or other tissues generalized bi- or triphasic “periodic sharp OR wave complexes” (PSWC) at a frequency . Rapidly progressive dementia AND at least two of the following clinical features: of 1-2 per second. No limitation on a) Myoclonus duration of illness. b) Visual or Cerebellar Signs . MRI: High signal abnormalities in the c) Pyramidal/Extrapyramidal Signs caudate nucleus and/or putamen OR in at d) Akinetic Mutism least two cortical regions (temporal, AND satisfying at least 1 of the supportive laboratory criteria, parietal, occipital) on diffusion-weighted AND absence of routine investigations indicating an alternative diagnosis imaging (DWI) or fluid attenuated inversion recovery (FLAIR). No limitation Possible: on duration of illness. Progressive dementia AND at least two of the following clinical features:

a) Myoclonus (Continued on next page– see Exclusion b) Visual or Cerebellar Signs Criteria.) c) Pyramidal/Extrapyramidal Signs d) Akinetic mutism

AND a duration of illness < 2 years,

AND the absence of any supportive laboratory criteria, AND the absence of routine investigations indicating an alternative diagnosis

53 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Prion diseases such as Sporadic Fatal Insomnia (sFI): Classification follows FFI criteria but is not epi-linked Exclusion Criterion: Creutzfeldt-Jakob disease (no 1st degree relatives with evidence of disease). On pathology the glycosylation On neurohistopathological analysis of whole (CJD) pattern is similar to sCJD rather than to FFI. brain autopsy tissue, the absence of findings consistent with prion disease (negative Variably Protease-Sensitive Prionopathy (VPSPr): (continued on next page) results) is sufficient to “rule out” possible Confirmed: Satisfactory confirmatory test findings on autopsy or biopsy of brain tissue and probable cases and reclassify as “Not a for variably protease sensitive prionopathy. Case”. Familial/Genetic CJD Classifications Notes: Whole brain autopsy and Familial CJD (fCJD): A classification of confirmed or probable requires: neuropathology is the only way to confirm . sCJD case classification criteria are met plus the presence of a confirmed or probable or rule-out prion disease. Biopsy tissue can CJD classification in a first degree relative only confirm presence of prion disease but is AND/OR not sufficient to rule-out prion disease. . a neuropsychiatric disorder plus fCJD-specific PRNP gene mutation. Autopsy or postmortem biopsy (when autopsy is not possible) is strongly Note: Fatal Familial Insomnia (FFI) and Gerstmann-Sträussler-Scheinker disease (GSS) encouraged, while biopsy on living patients are specific familial CJD diseases, and classification will be based on pathology results should be reserved for diagnosing treatable and/or a specific PRNP gene mutation for the disease and family history. diseases. The National Prion Disease Acquired CJD Classifications Pathology Surveillance Center (NPDPSC) performs analysis on CSF, blood, and brain Iatrogenic CJD (iCJD): tissue. They provide free transport, shipping, Confirmed: Progressive cerebellar syndrome in a recipient of human cadaveric-derived and autopsy services for suspected cases of pituitary hormone OR meets sCJD criteria WITH a recognized exposure risk (e.g., dura CJD (the family must initiate contact). matter grafts) Physicians are strongly encouraged to confirm the diagnosis of CJD by discussing & arranging autopsy with the NPDPSC and family members. Autopsy is “highly suggested” for all cases with onset age less than 55 years or physician diagnosed CJD that does not meet the epidemiologic case criteria.

54 Revision date: January – October 2020

Prion diseases such as Variant CJD (vCJD) is characterized by epidemiologic exposure to the causative agent of Confirmatory Laboratory Criteria – Creutzfeldt-Jakob disease bovine spongiform encephalopathy (BSE) through consumption of contaminated meat, a vCJD (brain tissue) (CJD) prolonged incubation period of ~ 8 years (possibly decades), and presence of a . Numerous widespread kuru-type amyloid neuropsychiatric disease that is progressive and invariably fatal. Median age at onset of plaques surrounded by vacuoles in both the symptoms is 28 years. Clinical presentation: early psychiatric symptoms cerebellum and cerebrum (i.e., florid (anxiety/depression), paraesthesia, delayed development of neurologic signs (> 4 plaques) AND months), and duration of illness lasting over 6 months. . Spongiform change and extensive prion protein deposition shown by Confirmed: Confirmatory laboratory criteria are met immunohistochemistry throughout the Suspect*: The following criteria are met: cerebellum and cerebrum a) Current age or age at death <55 years (a brain autopsy is recommended, however, Supportive Laboratory Criteria - vCJD for all physician-diagnosed CJD cases) . EEG with normal or abnormal findings BUT b) Psychiatric symptoms at illness onset AND/OR persistent painful sensory WITHOUT findings consistent with symptoms (frank pain and/or dysesthesia) sporadic CJD (absence of “periodic sharp c) Dementia AND development >4 months after illness onset of at least two of the wave complexes” - PSWC), OR EEG not following five neurologic signs: poor coordination, myoclonus, chorea, reported or performed hyperreflexia, or visual signs. (If persistent painful sensory symptoms exist, >4 . Presence of “bilateral pulvinar high signal” months delay in the development of the neurologic signs is not required.) OR “pulvinar sign” OR “symmetrical, d) A normal or an abnormal EEG, BUT NOT the diagnostic EEG changes often seen bilateral high signal in the posterior thalamic in classic CJD nuclei” on MRI (relative to other deep gray- e) Duration of illness of over 6 months matter nuclei) f) Routine investigations of the patient do not suggest an alternative, non-CJD Notes: Whole brain autopsy and diagnosis neuropathology is the only way to confirm g) No history of receipt of cadaveric human pituitary growth hormone or a dura mater or rule-out prion disease. Biopsy tissue can graft only confirm presence of prion disease but is h) No history of CJD in a first degree relative or PRNP gene mutation in the patient not sufficient to rule-out prion disease. OR Autopsy or postmortem biopsy (when . Presence of “bilateral pulvinar high signal” or “pulvinar sign” or “symmetrical, autopsy is not possible) is strongly bilateral high signal in the posterior thalamic nuclei” on MRI, AND encouraged, while biopsy on living patients . Presence of all of the following: a progressive neuropsychiatric disorder, d, e, f, & g should be reserved for diagnosing treatable of the above criteria diseases. The National Prion Disease AND four of the following five criteria: Pathology Surveillance Center (NPDPSC) . Early psychiatric symptoms (anxiety, apathy, delusions, depression, performs analysis on CSF, blood, and brain withdrawal) tissue. They provide free transport, shipping, . Persistent painful sensory symptoms (frank pain and/or dysesthesia, and autopsy services for suspected cases of and/or paraesthesia) CJD (the family must initiate contact). . Ataxia Physicians are strongly encouraged to . Myoclonus or chorea or dystonia confirm the diagnosis of CJD by discussing . Dementia & arranging autopsy with the NPDPSC and *A history of possible exposure to bovine spongiform encephalopathy (BSE) such as family members. Autopsy is “highly residence or travel to a BSE-affected country after 1980 increases the index of suspicion suggested” for all cases with onset age less for a variant CJD diagnosis. than 55 years or physician diagnosed CJD that does not meet the epidemiologic case criteria.

55 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Q Fever, acute Q fever is a zoonotic disease caused by . Asymptomatic infection occurs in . Serological evidence of a four-fold change 10257 approximately half of those infected. Exposure to Q fever is usually via aerosol, and the in IgG-specific antibody titer to C. burnetii source can be unknown (especially for chronic infection). Exposure can be associated with Phase II antigen by IFA between paired

goats, sheep, or other livestock, but direct contact with animals is not required, and variable serum samples (preferably one taken incubation periods can be dose dependent. Acute infection, if symptomatic, is characterized during the first week of illness and a by acute onset of fever accompanied by rigors, myalgia, malaise, and severe retrobulbar second 3-6 weeks later), headache, and can include fatigue, night sweats, dyspnea, confusion, nausea, diarrhea, OR abdominal pain, vomiting, non-productive cough, or chest pain. Acute hepatitis, atypical . Detection of C. burnetii DNA in a clinical pneumonia, and meningoencephalitis may be present with severe disease. Pregnant women specimen by PCR, are at risk for fetal death and abortion. Clinical laboratory findings can include elevated liver OR enzyme levels, leukocytosis, and thrombocytopenia. . Demonstration of C. burnetii antigen in a Clinical evidence: Acute fever and one or more of the following: rigors, severe retrobulbar clinical specimen by IHC, headache, acute hepatitis, pneumonia, or elevated liver enzyme levels. OR . Isolation of C. burnetii from a clinical Confirmed: A clinically compatible case that is laboratory confirmed specimen in cell culture Probable: A clinically compatible case with a single supportive IgG-specific antibody titer to C. burnetii Phase II antigen of >1:128 by IFA, and the absence of a more likely clinical explanation

Q Fever, chronic Chronic Q fever is characterized by a Coxiella burnetii infection that persists for more than 6 . Serological evidence of IgG antibody to C. 10258 months. Potentially fatal endocarditis can evolve months to years after acute infection, burnetii Phase I antigen of >1:800 by IFA particularly in persons with underlying valvular disease. Infections of aneurysms and OR vascular prostheses have been reported. Immunocompromised individuals are particularly . Detection of C. burnetii DNA in a clinical susceptible. Rare cases of chronic hepatitis without endocarditis, osteomyelitis, osteoarthritis, specimen by PCR, and have been described. OR Clinical evidence: Chronic hepatitis, osteomyelitis, osteoarthritis, or pneumonitis (in the . Demonstration of C. burnetii antigen in a absence of other known etiology); suspected infection of a vascular aneurysm or vascular clinical specimen by IHC, prosthesis; or newly recognized, culture-negative endocarditis (particularly in a patient with OR previous valvulopathy or a compromised ). . Isolation of C. burnetii from a clinical specimen in cell culture Confirmed: A clinically compatible (meets clinical evidence criteria) case of chronic illness that is laboratory confirmed Probable: A clinically compatible case of chronic illness with an antibody titer to C. burnetii Phase I IgG antigen that is >1:128 and <1:800 by IFA

56 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Rabies, animal All warm-blooded animals, including humans, are susceptible to rabies. In Texas, skunks, . A positive DFA test (preferably performed 10340 bats, coyotes, and foxes are the most commonly infected animals. Domestic dogs, cats, and on central nervous system tissue), livestock usually acquire rabies infections from wild animals. OR Medical authorities distinguish between "furious" and "dumb" rabies on the basis of clinical . Isolation of rabies virus (in cell culture or in signs. In the furious variety, the "mad dog" symptoms are pronounced. The animal is irritable a laboratory animal) and will snap and bite at real or imaginary objects. It can run for miles and attack anything in OR its path. The animal is extremely vicious and violent. Paralysis sets in shortly, usually . Detection of Lyssavirus viral RNA using affecting the hind legs first. Death follows four to seven days after the onset of clinical signs. RT-PCR in saliva, CSF, or tissue In dumb rabies, the prominent symptoms are drowsiness and paralysis of the lower jaw. The OR animal can appear to have a bone lodged in its throat, sometimes causing owners to force . Detection of rabies virus antigens in central open an animal's mouth to investigate and become unwittingly exposed to rabies. Animals nervous system tissues by IHC with dumb rabies have no tendency to roam but will snap at movement. They are completely insensitive to pain, and usually become comatose and die from three to ten days after first symptoms appear. Confirmed: A case that is laboratory confirmed

Rabies, human Rabies is an acute encephalomyelitis that almost always progresses to coma or death within . Detection of Lyssavirus antigens in a 10460 10 days after the first symptom. clinical specimen (preferably the brain or the nerves surrounding hair follicles in the Confirmed: A clinically compatible case that is laboratory confirmed by testing at a state or nape of the neck) by DFA, federal public health laboratory OR Note: Laboratory confirmation by all of the methods listed under “Lab Confirmation Tests” . Isolation (in cell culture or in a laboratory is strongly recommended. animal) of Lyssavirus from saliva, CSF, or central nervous system tissue, OR . Identification of Lyssavirus specific antibody (i.e., by IFA or complete rabies virus neutralization at 1:5 dilution) in the CSF, OR . Identification of Lyssavirus specific antibody (i.e., by IFA or complete rabies virus neutralization at 1:5 dilution) in the serum of an unvaccinated person, OR . Detection of Lyssavirus viral RNA using RT-PCR in saliva, CSF, or tissue

57 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Rickettsiosis, unspecified Flea-borne typhus and spotted fever group rickettsioses (SFGR) are a group of vector- Not applicable – see note 65466 borne infections caused by some members of the genus Rickettsia. These infections can be difficult to differentiate clinically and serologically due to antibody cross-reactivity.

Clinical evidence: Acute onset of fever and two or more of the following: rash, headache, nausea/vomiting, myalgia, anemia, thrombocytopenia, or elevated liver enzymes. Probable: A case that meets clinical criteria with similar elevations* in IgG serologic titers (≥1:128 to spotted fever and typhus group antigens) in a sample taken within 60 days of illness onset that cannot be definitively classified as spotted fever rickettsiosis or flea- borne typhus and does not have a more likely clinical explanation. *Serologic IgG titers that are equal or within one dilution of each other Note: For “Rickettsiosis, unspecified,” an undetermined case can only be classified as probable. See Rickettsia Classification

Rubella An illness that has all the following characteristics: Acute onset of generalized . Isolation of rubella virus, 10200 maculopapular rash; temperature ≥99oF (37.2oC), if measured; and arthralgia/arthritis, OR lymphadenopathy, or conjunctivitis. . Significant rise between acute- and Confirmed: A case that is clinically compatible and is laboratory confirmed or convalescent-phase titers in serum rubella epidemiologically linked to a laboratory-confirmed case immunoglobulin G (IgG) antibody level* by any standard serologic assay, Note: Serum rubella IgM test results that are false positives have been reported in OR persons with other viral infections (e.g., acute infection with Epstein-Barr virus . Positive serologic test for rubella-specific [infectious mononucleosis], recent cytomegalovirus infection, and parvovirus infection) immunoglobulin M (IgM) antibody* not or in the presence of rheumatoid factor. Patients who have laboratory evidence of recent otherwise ruled out by more specific testing measles infection are excluded. in a public health laboratory, OR . Detection of rubella-virus-specific nucleic acid by PCR *Not explained by MMR vaccination during the previous 6-45 days.

58 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Rubella, congenital An illness of newborns resulting from rubella infection in utero and characterized by signs or . Isolation of rubella virus, syndrome symptoms from the following categories: OR 10370 a) Cataracts/congenital glaucoma, congenital heart disease (most commonly patent . Demonstration of rubella-specific ductus arteriosus or peripheral pulmonary artery stenosis), hearing loss, or pigmentary immunoglobulin M (IgM) antibody, retinopathy OR b) Purpura, hepatosplenomegaly, jaundice, microcephaly, developmental delay, . Infant rubella antibody level that persists at a meingoencephalitis, or radiolucent bone disease higher level and for a longer period than expected from passive transfer of maternal Confirmed: A clinically consistent case that is laboratory confirmed antibody (i.e., rubella titer that does not drop Probable: A case that is not laboratory confirmed, that has any two complications listed in at the expected rate of a twofold dilution per (a) of the clinical case definition or one complication from (a) and one from (b), and lacks month), evidence of any other etiology OR . Detection of rubella-virus-specific nucleic acid by PCR

Salmonella Paratyphi An illness caused by Salmonella Paratyphi serotypes A, B (tartrate negative), and C that is . Isolation of S. Paratyphi A, B (tartrate 50266 often characterized by insidious onset of fever, diarrhea, abdominal cramps, constipation, negative), or C from a clinical specimen anorexia, and relative bradycardia. Confirmed: Confirmatory laboratory criteria are met Probable: . A clinically compatible case with S. Paratyphi A, B (tartrate negative), or C detected by use of culture independent laboratory methods (non-culture based), OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Notes: . Both asymptomatic infections and infections at sites other than the gastrointestinal tract, if laboratory confirmed, are considered confirmed cases that should be reported. . Carriage of S. Paratyphi A, B (tartrate negative), and C can be prolonged. A case should not be counted as a new case if laboratory results were reported within 365 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different serotype.

59 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Salmonella Typhi An illness caused by Salmonella Typhi that is often characterized by insidious onset of fever, . Isolation of S. Typhi from blood, stool, or 50267 diarrhea, abdominal cramps, constipation, anorexia, and relative bradycardia. other clinical specimen

Confirmed: Confirmatory laboratory criteria are met

Probable: . A clinically compatible case with S. Typhi detected by use of culture independent laboratory methods (non-culture based), OR  A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Notes: . Both asymptomatic infections and infections at sites other than the gastrointestinal tract, if laboratory confirmed, are considered confirmed cases that should be reported. . Carriage of S. Typhi can be prolonged. A case should not be counted as a new case if laboratory results were reported within 365 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different serotype.

Salmonellosis, non- An illness of variable severity commonly manifested by diarrhea, fever, abdominal pain, . Isolation of Salmonella (excluding S. Typhi Paratyphi/non-Typhi nausea, and sometimes vomiting. Asymptomatic infections can occur, and the organism and S. Paratyphi [A, B (tartrate negative), 50265 can cause extraintestinal infections. and C])* from a clinical specimen

Confirmed: A case that meets the laboratory criteria for diagnosis. When available, Notes:

Salmonella serotype characterization should be reported *S. Typhi is reportable as Salmonella Typhi.

Probable: *S. Paratyphi is reportable as Salmonella . A case with Salmonella sp. (excluding S. Typhi and S. Paratyphi [A, B (tartrate Paratyphi. negative), and C]) detected by use of culture independent laboratory methods (non- culture based), OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Notes: . A case with isolation of S. Paratyphi B (tartrate positive) from a clinical specimen should be reported as a salmonellosis, non-Paratyphi/non-Typhi case. . Both asymptomatic infections and infections at sites other than the gastrointestinal tract, if laboratory confirmed, are considered confirmed cases that should be reported. . A case should not be counted as a new case if laboratory results were reported within 365 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different serotype.

60 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Shiga toxin-producing An infection of variable severity characterized by diarrhea (often bloody) and abdominal . Isolation of Shiga toxin-producing Escherichia coli (STEC) cramps. Illness can be complicated by hemolytic uremic syndrome (HUS) or thrombotic Escherichia coli from a clinical specimen 11563 thrombocytopenic purpura (TTP); asymptomatic infections also can occur and the organism . Escherichia coli O157:H7 isolates are can cause extraintestinal infections. assumed to be Shiga toxin-producing. Confirmed: A case that meets the laboratory criteria for diagnosis; when available, O and H Therefore, isolation alone qualifies a case as antigen serotype characterization should be reported “confirmed.” . Escherichia coli non-O157:H7 isolates must Probable: also have Shiga toxin-production verified in . A case with isolation of E. coli O157 from a clinical specimen, without confirmation of order to qualify the case status as H antigen or Shiga toxin-production, OR “confirmed.” Shiga toxin can be . A clinically compatible case that is epidemiologically linked to a confirmed or probable demonstrated by EIA or PCR testing. case, OR . EIA and/or PCR positive results for Shiga . Identification of an elevated antibody titer to a known Shiga toxin-producing E. coli toxin-production, in the absence of an serotype from a clinically compatible case, OR isolate, can only qualify a case as . Identification of Shiga toxin in a specimen from a clinically compatible case without the “probable.” isolation of the Shiga toxin-producing E. coli, OR . A clinically compatible illness in a person with detection of Shiga toxin or Shiga toxin Note: As required by TAC, all E.coli 0157:H7, genes in a clinical specimen using a CIDT and no known isolation of from a isolates or specimens from cases where Shiga- clinical specimen, OR toxin activity is demonstrated must be submitted to the DSHS Laboratory. . A clinically compatible illness in a person with detection of E. coli O157 or STEC in a clinical specimen using a CIDT

Suspect: A case with no known clinical compatibility and detection of . Shiga toxin or Shiga toxin genes in a clinical specimen using a CIDT and no known isolation of Shigella from a clinical specimen, OR . Detection of E. coli O157 or STEC in a clinical specimen using a CIDT

Notes: . Cases meeting confirmed or probable criteria for both STEC and HUS should be reported under each condition. . A case should not be counted as a new case if a positive laboratory result is reported within 180 days of a previously reported positive laboratory result in the same individual, unless additional information is available indicating a separate infection

61 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Shigellosis An illness of variable severity characterized by diarrhea, fever, nausea, cramps, and . Isolation of Shigella from a clinical 11010 tenesmus. Asymptomatic infections can occur. specimen Confirmed: A case that meets the laboratory criteria for diagnosis. When available, Shigella serogroup or species and serotype characterization should be reported. Probable: . A case with Shigella spp. or Shigella detected, in a clinical specimen, by use of culture independent laboratory methods (non-culture based), OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Notes: . Both asymptomatic infections and infections at sites other than the gastrointestinal tract, if laboratory confirmed, are considered confirmed cases that should be reported. . A case should not be counted as a new case if laboratory results were reported within 90 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different serotype.

Smallpox An illness with acute onset of fever ≥101º F (≥38.3 º C) followed by a rash characterized by firm, . Polymerase chain reaction (PCR) 11800 deep seated vesicles or pustules in the same stage of development without other apparent cause. identification of variola DNA in a clinical Confirmed: A case of smallpox that is laboratory confirmed, or a case that meets the clinical specimen, case definition and is epidemiologically linked to a laboratory confirmed case OR Probable: A case that meets the clinical case definition without laboratory confirmation or . Isolation of smallpox (variola) virus from a epidemiological link to a confirmed case, OR a case with an atypical presentation of clinical specimen (Level D laboratory only; smallpox (e.g., hemorrhagic type, flat type, and variola sine eruptione) that has an confirmed by variola PCR) epidemiological link to a confirmed case of smallpox. (Detailed clinical description is available on the CDC web site, see Note: Laboratory diagnostic testing for variola https://www.cdc.gov/smallpox/clinicians/clinical-disease.html. virus should be conducted in a CDC Suspect: A case with a generalized, acute vesicular or pustular rash illness with fever Laboratory Response Network (LRN) preceding development of rash by 1-4 days laboratory utilizing LRN-approved PCR tests and protocols for variola virus. Initial Exclusion Criteria: A case can be excluded as a suspect or probable smallpox case if an confirmation of a smallpox outbreak requires alternative diagnosis fully explains the illness or appropriate clinical specimens are negative additional testing at CDC. for laboratory criteria for smallpox. Note: The smallpox case definition above is to be used only during post-event surveillance. Generic orthopox PCR and negative stain For pre-event surveillance purposes, where the likelihood of smallpox occurring is considered to electron microscopy (EM) identification of a be extremely low, the suggested approach to surveillance relies on a highly specific clinical case pox virus in a clinical specimen are suggestive definition, which is focused on identifying a classic case (ordinary type) of smallpox. In the of an orthopox virus infection but not absence of known smallpox disease, the predictive value of a positive smallpox diagnostic test is diagnostic for smallpox. extremely low, close to zero; therefore, testing to rule out smallpox should be limited to cases that fit the clinical case definition in order to lower the risk of obtaining a false positive test result. For post-event enhanced surveillance and case reporting guidance see https://www.cdc.gov/smallpox/bioterrorism-response-planning/public-health/enhanced- surveillance-case-reporting.html.

62 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Spotted fever rickettsiosis Spotted fever group rickettsioses (SFGR) are a group of tick-borne infections caused by . Serological evidence of aa four-fold increase 10250 some members of the genus Rickettsia. The most well-known SFGR is Rocky Mountain in IgG-specific antibody titer reactive with spotted fever (RMSF), an illness caused by . Disease onset for RMSF SFGR** antigen by IFA between paired averages one week following a tick bite. Illness is characterized by acute onset of fever and acute (taken in the first two weeks after can be accompanied by headache, malaise, myalgia, nausea/vomiting, or neurologic signs; a illness onset) and convalescent (taken two to macular or maculopapular rash may appear 4-7 days following onset in many (~80%) ten weeks after acute specimen collection) patients, often present on the palms and soles. RMSF can be fatal in as many as 20% of serum specimens, untreated cases, and severe fulminant disease can occur. In addition to RMSF, human illness OR associated with other spotted fever group (SFG) Rickettsia species, including infection with . Detection of SFGR** nucleic acid in a R. parkeri, has also been reported. In these patients, clinical presentation appears similar to, clinical specimen via amplification of a but can be milder than, RMSF; the presence of an eschar at the site of tick attachment has species-specific target by PCR assay, been reported for some other SFGR. OR Clinical evidence: Any reported acute onset of fever and one or more of the following: rash, . Demonstration of SFGR** antigen in a eschar, headache, myalgia, anemia, thrombocytopenia, or any hepatic transaminase biopsy or autopsy specimen by IHC, elevation. OR Confirmed: Clinically compatible case (meets clinical evidence criteria) that is laboratory . Isolation of SFGR** from a clinical confirmed specimen in cell culture and molecular Probable: Clinically compatible case with serological evidence of elevated IgG antibody confirmation (e.g., PCR or sequence). reactive with SFGR antigen* by IFA (serologic titer of ≥1:128; specimen collected within 60 **Spotted fever group Rickettsia included in days of onset) and the absence of a more likely clinical explanation SFGR are R. aeschlimannii, R. africae, R. Notes: australis, R. conorii, R. heilongjiangensis, R. . Because antibodies for rickettsial diseases can be cross-reactive, specimens should be helvetica, R. honei, R. japonica, R. marmionii, tested against a panel* of Rickettsia antigens, including, at a minimum, R. rickettsii R. massiliae, R. parkeri, R. rickettsii, R. and R. typhi, to differentiate between SFG and non-SFG Rickettsia spp. sibirica, R. sibirica mongolotimonae, and R. . A case should not be counted as new if the case has ever previously been reported for slovaca. Spotted fever group species excluded the same condition. from this condition are R. felis and R. akari. * Specimens can be forwarded to the DSHS Serology lab for rickettsial panel testing. See Rickettsia Classification

63 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Streptococcal toxic shock Streptococcal toxic-shock syndrome (STSS) is a severe illness associated with invasive or . Isolation of group A Streptococcus (S. syndrome (Outbreaks only) noninvasive group A streptococcal (Streptococcus pyogenes) infection. STSS may occur pyogenes) (GAS) 11700 with infection at any site but most often occurs in association with infection of a cutaneous lesion. Signs of toxicity and a rapidly progressive clinical course are characteristic, and the case fatality rate may exceed 50%. An illness with the following clinical manifestations: 1) Hypotension defined by a systolic blood pressure less than or equal to 90 mm Hg for adults or less than the fifth percentile by age for children aged less than 16 years, AND 2) Multi-organ involvement characterized by two or more of the following: . Renal Impairment: Creatinine greater than or equal to 2 mg/dL (greater than or equal to 177 µmol/L) for adults or greater than or equal to twice the upper limit of normal for age. In patients with preexisting renal disease, a greater than twofold elevation over the baseline level. . Coagulopathy: Platelets less than or equal to 100,000/mm3 (less than or equal to 100 x 106/L) or disseminated intravascular coagulation, defined by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products . Liver Involvement: Alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than or equal to twice the upper limit of normal for the patient's age. In patients with preexisting liver disease, a greater than twofold increase over the baseline level. . Acute Respiratory Distress Syndrome: Defined by acute onset of diffuse pulmonary infiltrates and hypoxemia in the absence of cardiac failure or by evidence of diffuse capillary leak manifested by acute onset of generalized edema, or pleural or peritoneal effusions with hypoalbuminemia . A generalized erythematous macular rash that may desquamate . Soft-tissue , including or myositis, or Confirmed: A case that meets the clinical case definition and is laboratory confirmed with isolation of group A Streptococcus from a normally sterile site (e.g., blood or cerebrospinal fluid or, less commonly, joint, pleural, or pericardial fluid) Probable: A case that meets the clinical case definition in the absence of another identified etiology for the illness and with isolation of group A Streptococcus from a non-sterile site Note: Enter all confirmed and probable STSS cases as confirmed group A Streptococcus, invasive disease, code 11710. See also Streptococcus, invasive group A (GAS) disease (Streptococcus pyogenes), code 11710.

64 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Streptococcus, invasive group Invasive group A streptococcal infections may manifest as any of several clinical syndromes, . Isolation of group A Streptococcus A (GAS) disease including pneumonia, bacteremia in association with cutaneous infection (e.g., cellulitis, (Streptococcus pyogenes) by culture from a (Streptococcus pyogenes) , or infection of a surgical or nonsurgical wound), deep soft-tissue infection (e.g., normally sterile site (e.g., blood or 11710 myositis or necrotizing fasciitis), meningitis, peritonitis, osteomyelitis, septic arthritis, cerebrospinal fluid, or, less commonly, joint, postpartum (i.e., puerperal fever), neonatal sepsis, and non-focal bacteremia. pleural, or pericardial fluid), Confirmed: A case that is laboratory confirmed OR . Isolation of group A Streptococcus Note: A person with group A Streptococcus isolated 2 or more times within a 6-month (Streptococcus pyogenes) by culture from timeframe (regardless of calendar year) should only be counted once as a case unless any site when or additional information is available to indicate a distinct infection, e.g., different Necrotizing Fasciitis is present serotype, etc. See Normally Sterile Site and Streptococcus Classification

Streptococcus, invasive group Group B Streptococcus is the most common cause of life-threatening infections, sepsis . Isolation of group B Streptococcus B (GBS) disease (blood infection), and meningitis (infection of the fluid and lining around the brain) in (Streptococcus agalactiae) by culture from a (Streptococcus agalactiae) newborns. In infants, group B Streptococcus is characterized by sepsis, respiratory distress, normally sterile site (e.g., blood or 11715 apnea, shock, pneumonia and meningitis. GBS is acquired in utero or during delivery and cerebrospinal fluid, or, less commonly, joint, occurs more frequently in low birth weight infants. pleural, or pericardial fluid), Group B Streptococcus invasive disease can present in a number of different ways in adults. OR The most common problems in adults are bloodstream infections, pneumonia, skin and soft- . Isolation of group B Streptococcus tissue infections, and bone and joint infections. Rarely, group B Streptococcus can cause (Streptococcus agalactiae) by culture from meningitis in adults. placenta or amniotic fluid from an intact Confirmed: A case that is laboratory confirmed amnion Notes: See Normally Sterile Site and Streptococcus . Only count one GBS case for a mother/baby pair unless both mother and baby have GBS Classification isolated/cultured from a sterile site (for this consideration, placenta and amniotic fluid are not sterile sites). In the event of a stillbirth or fetal death, if GBS is isolated from the placenta or amniotic fluid and there is no GBS culture available from a sterile site, count once as a maternal case. . A person with group B Streptococcus isolated 2 or more times within a 6-month timeframe (regardless of calendar year) should only be counted once as a case unless additional information is available indicating a distinct infection, e.g., different serotype, etc.

65 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Streptococcus pneumoniae, Streptococcus pneumoniae bacteria cause many clinical syndromes, depending on the . Isolation of S. pneumoniae from a invasive disease (IPD) site of infection (e.g., acute otitis media, pneumonia, bacteremia, or meningitis). Only normally sterile site (e.g., blood or 11723* invasive Streptococcus pneumoniae is reportable. cerebrospinal fluid, or, less commonly, joint, pleural, or pericardial fluid) Confirmed: A case that is laboratory confirmed *Note: Code 11717 was used See Normally Sterile Site and Streptococcus prior to 2010 and for 2010 Probable: A case with detection of S. pneumoniae from a normally sterile site using a Classification there are cases under both culture independent diagnostic test (CIDT) (e.g., PCR, antigen based tests) without codes. isolation of the bacteria Note: Serotyping of isolates can be performed at the DSHS laboratory. Note: Positive lab results from a specimen collected more than 30 days after the Serotyping is required by TAC for invasive collection date of a prior case should be counted as a new case. If specimen collection streptococcus pneumoniae cases on all occurred within 30 days of the collection date of a prior case, it should not be counted as isolates from children under 5 years old. a new case.

Taenia solium and Taeniasis is an intestinal infection with the adult stage of the pork (T. solium) or beef (T. . Infection with an adult tapeworm is undifferentiated Taenia saginata) tapeworms. Clinical manifestations of infection with the adult worm, if diagnosed by identification of proglottids infection present, are variable and can include nervousness, insomnia, anorexia, weight loss, (segments), eggs, or antigens of the worm 80680 abdominal pain, and digestive disturbances; many infections are asymptomatic. in the feces or on anal swabs Taeniasis is usually a nonfatal infection, but the larval stage of T. solium can cause fatal Note: Eggs of T. solium and T. saginata cysticercosis. cannot be differentiated morphologically. Confirmed: Laboratory identification of the presence of T. solium proglottids, eggs, or Specific diagnosis is based on the antigens in a clinical specimen morphology of the scolex (head) and/or gravid proglottids. Probable: Laboratory identification of the presence of undifferentiated Taenia spp. tapeworm proglottids or eggs in a clinical specimen See Cysticercosis

Tetanus Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles Not applicable 10210 of the jaw and neck) and generalized muscle spasms without other apparent medical cause Probable: A clinically compatible case, as reported by a health-care professional

66 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Trichinellosis (Trichinosis) A disease caused by ingestion of Trichinella larvae. The disease has variable clinical . Demonstration of Trichinella spp. larvae 10270 manifestations. Common signs and symptoms include eosinophilia, fever, myalgia, and in tissue obtained by muscle biopsy, periorbital edema. OR . Positive serologic test for Trichinella spp. Confirmed: A clinically compatible case that is laboratory confirmed in the patient Probable: A clinically compatible illness in a person who shared an epidemiologically implicated meal or ate an epidemiologically implicated meat product, OR a clinically compatible illness in a person who consumed a meat product in which the parasite was demonstrated Suspect: Instances where there is no clinically compatible illness in a person who shared an implicated meal or ate an implicated meat product, has no known prior history of Trichinella infection, and has a positive serologic test for trichinellosis Notes: . Epidemiologically implicated meals or meat products are defined as a meal/meat product that was consumed by a person who subsequently developed a clinically compatible illness that was laboratory confirmed. . Subsequent cases of trichinellosis experienced by one individual should only be counted if there is a clinically-compatible illness AND a compatible exposure.

Trichuriasis A parasitic infection caused by the soil-transmitted helminth Trichuris trichiura. People . Microscopic identification of Trichuris eggs 80790 with light infections usually have no symptoms or only peripheral blood eosinophilia. People or worms in feces, with heavy symptoms can experience frequent, painful passage of stool that contains a OR mixture of , water, and blood. Rectal prolapse can also occur. Children with heavy . Observation during sigmoidoscopy, infections can become severely anemic and growth-retarded. proctoscopy, or colonoscopy of Trichuris worms characterized by a threadlike form Confirmed: A case that is laboratory confirmed with an attenuated, whip-like end,

OR . Identification of Trichuris worms on prolapsed rectal mucosa

67 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Tularemia The signs and symptoms of tularemia vary depending on how the bacteria enter the body. . Isolation of F. tularensis in a clinical or 10230 Illness ranges from mild to life-threatening. All forms are accompanied by fever, which can be autopsy specimen, as high as 104 °F. Clinical diagnosis is supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian of , or exposure to OR potentially contaminated water. Illness is characterized by several distinct forms, including the . Four-fold or greater rise in serum antibody following: titer* to F. tularensis antigen between acute . Ulceroglandular: cutaneous ulcer with regional lymphadenopathy and convalescent specimens. . Glandular: regional lymphadenopathy with no ulcer Note: As required by TAC, all F. tularensis . Oculoglandular: conjunctivitis with preauricular lymphadenopathy isolates must be submitted to the DSHS . Oropharyngeal: stomatitis or pharyngitis or tonsillitis and cervical lymphadenopathy Laboratory. . Pneumonic: primary pleuropulmonary disease . Typhoidal: febrile illness without early localizing signs and symptoms Confirmed: A clinically compatible case with confirmatory laboratory results Probable: A clinically compatible case with laboratory results indicative of presumptive infection and the absence of a more likely clinical explanation: . Elevated serum antibody titer(s)* to F. tularensis antigen (without documented fourfold or greater change) in a patient with no history of tularemia vaccination, OR . Detection of F. tularensis in a clinical or autopsy specimen by fluorescent assay OR . Detection of F. tularensis in a clinical or autopsy specimen by PCR *ELISAs are qualitative tests and thus do not provide a titer. Samples that test positive by ELISA should be forwarded to DSHS for tularemia serologic testing to validate results.

68 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Typhus, flea-borne (endemic, Flea-borne typhus is a rickettsial disease whose course resembles that of louse-borne typhus, . Serological evidence of a four-fold murine) but is generally milder. The onset is variable, often sudden and marked by headache, chills, increase in IgG-specific antibody titer 10260 fatigue, fever, and general body aches. A macular rash may appear on the 5th or 6th day, reactive with R. typhi by IFA test between initially on the upper trunk, followed by spread to the entire body, but usually not to the face, paired serum specimens (preferably one palms or soles. Absence of louse infestation, geographic and seasonal distribution, and taken in the first two weeks of illness and a sporadic occurrence of the disease help to differentiate it from louse-borne typhus. second up to ten weeks later), Clinical evidence: Any reported acute onset of fever and two or more of the following: OR headache, myalgia, rash, nausea/vomiting, thrombocytopenia, or any elevated liver enzyme . Detection of R. typhi nucleic acid via amplification of R. typhi target by rt-PCR Confirmed: Clinically compatible case that is laboratory confirmed assay Probable: Clinically compatible case with evidence of epidemiologic linkage*, the absence OR of a more likely clinical explanation, and supportive lab evidence: . Demonstration of typhus fever group . Serologic evidence of elevated IgG at a titer of ≥1:128 reactive with R. typhi antigen in a biopsy or autopsy specimen antigen by IFA in a sample taken within 60 days of illness onset, OR by IHC, . Serologic evidence of elevated IgM at a titer of ≥1:256 reactive with R. typhi antigen by IFA in a sample taken within 60 days of illness onset. OR *Epidemiologic linkage criteria: Was in same household or had same defined exposure . Isolation of R. typhi from a clinical as a confirmed case within the past 14 days before onset of symptoms, OR likely vector specimen in cell culture and molecular exposure in an area with suitable seasonal and ecological conditions for potential local confirmation (e.g., PCR or sequence) vector-borne transmission Notes: . Because antibodies for rickettsial diseases can be cross-reactive, specimens should be tested against a panel** of Rickettsia antigens, including, at a minimum, R. rickettsii and R. typhi, to differentiate between SFG and non-SFG Rickettsia spp. . According to CDC, rickettsial IgM tests lack specificity (resulting in false positives); thus, IgG titers are much more reliable. . A case should not be counted as new if the case has ever previously been reported for the same condition. ** Specimens can be forwarded to the DSHS Serology Laboratory for rickettsial panel testing. See Rickettsia Classification

69 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Typhus fever (epidemic, A rickettsial disease caused by and transmitted by the human body . Four-fold or greater rise in IgG-specific louse-borne) louse. The illness may have a variable onset which is often sudden and marked by antibody titer to R. prowazekii antigen by 10265 headache, chills, prostration, fever, and general body aches. A macular rash may appear IFA test in acute and convalescent on the 5th or 6th day, initially on the upper trunk, followed by spread to the entire body, specimens ideally taken at least 2 weeks but usually not to the face, palms or soles. The rash is often difficult to observe on dark apart, skin. Toxemia is usually pronounced, and the disease terminates by rapid defervescence OR after about 2 weeks of fever. . Positive PCR assay to R. prowazekii, Confirmed: Clinically compatible case that is laboratory confirmed OR Probable: Clinically compatible case with supportive laboratory results and the absence . Demonstration of positive R. prowazekii of a more likely clinical explanation: IHC of skin lesion (biopsy) or organ tissue . IFA serologic titer of ≥1:128 (autopsy) Note: The IFA test is most commonly used for laboratory confirmation, but it does not discriminate between louse-borne and flea-borne typhus unless the sera are differentially absorbed with the respective rickettsial antigen prior to testing. See Rickettsia Classification

Vancomycin-intermediate Staphylococcus aureus can produce a variety of syndromes with clinical manifestations . Isolation of Staphylococcus aureus from Staphylococcus aureus including skin and soft tissue lesions, empyema, pyarthrosis, bloodstream infection, any body site, (VISA) pneumonia, osteomyelitis, septic arthritis, endocarditis, sepsis, and meningitis. AND 11663 . Intermediate-level resistance (MIC: 4-8 Confirmed: A vancomycin-intermediate Staphylococcus aureus from any body site that is µg/ml) of the Staphylococcus aureus laboratory confirmed. (MIC: 4-8 µg/ml) isolate to vancomycin, detected and defined according to CLSI approved Note: The DSHS Laboratory uses the Etest for confirmation of resistance. Etest generates standards and recommendations. MIC values from a continuous scale and can give results in-between conventional two- AND fold dilutions. According to manufacturer’s protocol, a value which falls between . Confirmed by the DSHS Laboratory standard two-fold dilutions is rounded up to the next upper two-fold value before Note: As required by TAC, all categorization so that a MIC of 3µg/ml is reported as intermediate resistance. Staphylococcus aureus isolates with a Additional information on VISA can be found at: vancomycin MIC greater than 2 µg/mL must https://www.cdc.gov/hai/organisms/visa_vrsa/visa_vrsa.html be submitted to the DSHS Laboratory. Please contact a DSHS HAI Epidemiologist or the DSHS Laboratory for additional information on available laboratory support. http://www.cdc.gov/HAI/settings/lab/visa_v rsa_lab_detection.html

70 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Vancomycin-resistant Staphylococcus aureus can produce a variety of syndromes with clinical manifestations . Isolation of Staphylococcus aureus from any Staphylococcus aureus including skin and soft tissue lesions, empyema, pyarthrosis, bloodstream infection, body site, (VRSA) pneumonia, osteomyelitis, septic arthritis, endocarditis, sepsis, and meningitis. AND 11665 Confirmed: A vancomycin-resistant Staphylococcus aureus from any body site that is . High-level resistance of the Staphylococcus laboratory confirmed. (MIC: > 16 µg/ml) aureus isolate to vancomycin (MIC: ≥16 µg/ml), detected and defined according to Additional information on VRSA can be found at: CLSI approved standards and https://www.cdc.gov/hai/organisms/visa_vrsa/visa_vrsa.html recommendations. AND . Confirmed by the DSHS Laboratory Note: As required by TAC, all Staphylococcus aureus isolates with a vancomycin MIC greater than 2 µg/mL must be submitted to the DSHS Laboratory. Please contact a DSHS HAI Epidemiologist or the DSHS Laboratory for additional information on available laboratory support. http://www.cdc.gov/HAI/settings/lab/visa_vrsa _lab_detection.html

Varicella (chickenpox) An illness with acute onset of diffuse (generalized) maculopapulovesicular rash without . Isolation of varicella-zoster virus (VZV) 10030 other apparent cause. In vaccinated persons who develop varicella more than 42 days after from a clinical specimen, vaccination (breakthrough disease), the disease is almost always mild with fewer than 50 OR skin lesions and shorter duration of illness. The rash can also be atypical in appearance . Varicella antigen detected by direct (maculopapular with few or no vesicles). fluorescent antibody (DFA), OR Confirmed: A case that meets the clinical case definition AND is either laboratory . Varicella-specific nucleic acid detected by confirmed, OR epidemiologically linked to another probable or confirmed case polymerase chain reaction (PCR), Probable: A case that meets the clinical case definition without epidemiologic linkage or OR laboratory confirmation . Significant rise in serum varicella immunoglobulin G (IgG) antibody level by Note: Two or more patients that meet clinical case definition and are epidemiologically any standard serologic assay linked to one another meet the confirmed case definition.

71 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Vibrio parahaemolyticus An intestinal disorder characterized by watery diarrhea and abdominal cramps in the . Isolation of Vibrio parahaemolyticus from a 11541 majority of cases, and sometimes with nausea, vomiting, fever and headache. Occasionally, a clinical specimen dysentery-like illness is observed with bloody or mucoid stools, high fever and high WBC Note: As required by TAC all Vibrio species count. Typically, it is a disease of moderate severity lasting 1-7 days; systemic infection and isolates must be submitted to the DSHS death rarely occur. Laboratory. Confirmed: A case that meets the laboratory criteria for diagnosis Probable: . A case with Vibrio parahaemolyticus detected, in a clinical specimen, by use of culture independent laboratory methods (non-culture based), OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Note: A case should not be counted as a new case if laboratory results were reported within 30 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different species

Vibrio vulnificus Infection with Vibrio vulnificus produces septicemia in persons with chronic liver disease, . Isolation of Vibrio vulnificus from a clinical 11542 chronic alcoholism or hemochromatosis, or those who are immunosuppressed. The disease specimen appears 12 hours to 3 days after eating raw or undercooked , especially . One third of patients are in shock when they present for care or develop hypotension within 12 Note: As required by TAC all Vibrio species hours after hospital admission. Three quarters of patients have distinctive bullous skin isolates must be submitted to the DSHS lesions; thrombocytopenia is common and there is often evidence of disseminated Laboratory. intravascular coagulation. V. vulnificus can also infect wounds sustained in coastal or estuarine waters; wounds range from mild, self-limited lesions to rapidly progressive cellulitis and myositis that can mimic clostridial myonecrosis in the rapidity of spread and destructiveness. Confirmed: A case that meets the laboratory criteria for diagnosis Probable: . A case with Vibrio vulnificus detected, in a clinical specimen, by use of culture independent laboratory methods (non-culture based), OR . A clinically compatible case that is epidemiologically linked to a case that meets the probable or confirmed laboratory criteria for diagnosis Note: A case should not be counted as a new case if laboratory results were reported within 30 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different species

72 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Vibriosis, other or unspecified An infection of variable severity characterized by diarrhea and vomiting, primary septicemia, . Isolation of a species of the family 11540 or wound infections. Asymptomatic infections can occur and the organism can cause (other than Vibrio extraintestinal infections parahaemolyticus, Vibrio vulnificus, and toxigenic Vibrio cholerae) from a clinical Confirmed: A case that meets the laboratory criteria for diagnosis specimen. Genera in the family Vibrionaceae Probable: currently include Aliivibrio, Allomonas, . A case with a species of the family Vibrionaceae (other than Vibrio parahaemolyticus, Catenococcus, Enterovibrio, Grimontia, Vibrio vulnificus, and toxigenic Vibrio cholerae O1 or O139) detected, in a clinical Listonella, Photobacterium, Salinivibrio, and specimen, by use of culture independent laboratory methods (non-culture based), OR Vibrio. . A clinically compatible case that is epidemiologically linked to a case that meets the Note: As required by TAC all Vibrio species probable or confirmed laboratory criteria for diagnosis isolates must be submitted to the DSHS Note: A case should not be counted as a new case if laboratory results were reported Laboratory. within 30 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection, e.g., different species

Viral Hemorrhagic Fever An illness with acute onset of fever, AND one or more of the following clinical findings: . Detection of VHF* viral antigens in blood (VHF) non-Ebola * severe headache, muscle pain, erythematous maculopapular rash on the trunk with flaking or by enzyme-linked immunosorbent assay shedding (fine desquamation) of the skin 3–4 days after rash onset, vomiting, diarrhea, (ELISA) antigen detection, 11640 Crimean-Congo HF abdominal pain, bleeding or bruising not related to injury, or thrombocytopenia. For OR 11648 Guanarito HF arenaviruses (Guanarito, Junin, Lassa, Lujo, Machupo, Sabia) pharyngitis, retrosternal chest . Isolation of VHF virus in cell culture for pain, or proteinuria may also occur. 11638 Junin (Argentine) HF blood or tissues, Confirmed: A clinically compatible illness that is laboratory confirmed OR 11632 Lassa fever . Detection of VHF specific genetic sequence 11644 Lujo HF Suspect: A clinically compatible illness that meets one or more of the following exposures within 21-days before onset of symptoms: by Reverse Transcription Polymerase Chain 11637 Machupo (Bolivian) HF . Contact with blood or other body fluids of a patient with VHF, OR Reaction (RT-PCR) from blood or tissues, OR 11631 Marburg fever . Residence in—or travel to—an VHF endemic area, OR . Work in a laboratory that handles VHF specimens, OR . Detection of VHF viral antigens in tissues by 11639 Sabia (Brazilian) HF . Work in a laboratory that handles primates, bats, or rodents infected with a VHF or from IHC an endemic area, OR *Viral hemmorhagic fever (VHF) agents . Exposure to semen of a confirmed acute or convalescent case of VHF within the last 12 include: *Viral Hemorrhagic Fevers months or breast-milk of an individual who had VHF within the last 6 months . Crimean-Congo hemorrhagic fever viruses include Ebola - please see . Ebola virus (see Ebola case definition) Ebola case definition for Ebola . Lassa virus specific information . Lujo virus . Marburg virus . New world arenaviruses (Guanarito, Machupo, Junin, Sabia viruses)

73 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Yellow fever Yellow fever virus is a mosquito-borne flavivirus that is closely related to dengue, Japanese . Isolation of yellow fever virus from, or 10660 encephalitis, West Nile, and Zika viruses.Yellow fever is preventable by a safe and effective demonstration of yellow fever viral antigen vaccine. or nucleic acid in, tissue, blood, CSF, or Most yellow fever virus infections are asymptomatic. Following an incubation period of 3–9 other body fluid, AND no history of yellow days, approximately one-third of infected people develop symptomatic illness characterized fever vaccination within 30 days before by fever and headache. Other clinical findings include chills, vomiting, myalgia, lumbosacral onset of illness unless there is molecular pain, and bradycardia relative to elevated body temperature. An estimated 5%–25% of evidence of infection with wild-type yellow patients progress to more severe disease, including jaundice, renal insufficiency, fever virus, cardiovascular instability, or hemorrhage (e.g., epistaxis, hematemesis, melena, hematuria, OR petechiae, or ecchymoses). The case-fatality rate for severe yellow fever is 30%–60%. . Four- fold or greater rise or fall in yellow fever virus-specific neutralizing antibody Clinical criteria: An acute illness with at least one of the following: fever, jaundice, or titers in paired sera, AND no history of elevated total bilirubin ≥3 mg/dl, and the absence of a more likely clinical explanation. yellow fever vaccination within 30 days Confirmed: A clinically compatible case that is laboratory confirmed before onset of illness, OR Probable: A clinically compatible case with supportive serology: . Yellow fever virus-specific IgM antibodies . Yellow fever virus-specific IgM antibodies in CSF or serum, AND negative IgM results in CSF or serum with confirmatory virus- for other arboviruses endemic to the region where exposure occurred, AND no history specific neutralizing antibodies in the same of yellow fever vaccination, or a later specimen, AND no history of AND yellow fever vaccination. . Epidemiologic linkage to a confirmed yellow fever case, or having visited or resided in an area with a risk of yellow fever in the 2 weeks before onset of illness.

Yersiniosis An illness characterized with either diarrhea that may or may not be bloody or abdominal . Isolation* of Yersinia (except Y. pestis**) in 11565 pain that may be severe enough to mimic appendicitis. a clinical specimen

Note: Extra-intestinal manifestations may also be present, such as abscess, which could be a *As required by TAC all Yersinia pestis source for testing, and and erythema nodosum, which are often isolates must be submitted to the DSHS immunologic phenomena not directly caused by the infection. These manifestations are not Laboratory. required as part of the clinical criteria. **For Yersinia pestis isolates, see Plague Confirmed: A case that meets the laboratory criteria for diagnosis Probable: A clinically compatible case that is epidemiologically linked to a confirmed case or a clinically compatible case identified through use of a culture independent diagnostic test (CIDT) such as PCR. Note: A case should not be counted as a new case if laboratory results were reported within 365 days of a previously reported infection in the same individual, unless additional information is available indicating a separate infection

74 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Zika disease, congenital Clinical evidence: A neonate with one or more of the following not explained by . Detection of ZIKV by culture, viral 50224 another etiology: antigen or viral RNA in fetal tissue, . congenital microcephaly umbilical cord blood, or amniotic fluid . congenital intracranial calcification with a validated diagnostic test . other structural brain or eye abnormalities OR . other congenital central nervous system-related abnormalities including defects such . Detection of ZIKV by culture, viral as clubfoot or multiple joint contractures antigen or viral RNA in neonatal serum, CSF, or urine collected within 2 days of Confirmed: A clinically compatible neonate with laboratory confirmation. birth** Probable: A clinically compatible neonate whose mother has an epidemiologic link* OR OR meets laboratory criteria for recent ZIKV or flavivirus infection; AND the neonate . Positive ZIKV IgM antibody test of has laboratory evidence of recent ZIKV or flavivirus infection by: umbilical cord blood, neonatal serum or . Positive ZIKV IgM antibody test of serum or CSF within 2 days of birth**; AND CSF collected within 2 days of birth** . positive neutralizing antibody titers against ZIKV and dengue or other with positive ZIKV neutralizing antibody flaviviruses endemic to the region where exposure occurred; OR titers and negative neutralizing antibody . negative dengue virus IgM antibody test and no neutralizing antibody test titers against dengue or other flaviviruses performed endemic to the region where exposure occurred *Epidemiologic link defined as one or more of the following: . Resides in or recent travel to an area with known ZIKV transmission, OR . Sexual contact with a confirmed or probable case of ZIKV infection or person with recent travel to an area with known ZIKV transmission; OR . Receipt of blood or blood products within 30 days of symptom onset; OR . Organ or tissue transplant recipient within 30 days of symptom onset; OR . Association in time or place with a confirmed or probable case; OR . Likely vector exposure in an area with suitable seasonal and ecological conditions for potential local vectorborne transmission **The requirement that samples be collected within 2 days only applies to areas with ongoing local Zika transmission.

75 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Zika disease, non-congenital A mosquito-borne viral illness transmitted by Aedes mosquitoes, including Ae. aegypti . Detection of ZIKV by culture, viral 50223 and Ae. albopictus. Infection is asymptomatic in up to 80% of cases and clinical illness, antigen or viral RNA in serum, CSF, when it occurs, is typically mild and lasts for several days to a week. Transmission of tissue, or other specimen (i.e. amniotic Zika virus (ZIKV) in utero has been associated with severe birth outcomes, including fluid, urine, semen, saliva) with a microcephaly and fetal loss. validated diagnostic test Clinical evidence: An individual with one or more of the following not explained by OR another etiology: . Positive ZIKV IgM antibody test in . Clinically compatible illness that includes: serum or CSF with positive ZIKV . acute onset of fever (measured or reported), or neutralizing antibody titers and negative . rash, or neutralizing antibody titers against . arthralgia, or dengue or other flaviviruses endemic to . conjunctivitis the region where exposure occurred . Complication of pregnancy . fetal loss, or . fetus or neonate with congenital microcephaly, congenital intracranial calcification, other structural brain or eye abnormalities, or other congenital central nervous system-related abnormalities including defects such as clubfoot or multiple joint contractures (note: if detected prior to infant’s birth, the relevant birth defects must be documented in at least two separate ultrasounds and/or verified at birth) . Guillain-Barrė syndrome or other neurologic manifestations Confirmed: A clinically compatible individual with laboratory confirmation. Probable: A clinically compatible individual with an epidemiologic link* AND laboratory evidence of recent ZIKV or flavivirus infection by: . Positive ZIKV IgM antibody test of serum or CSF with: . positive neutralizing antibody titers against ZIKV and dengue or other flaviviruses endemic to the region where exposure occurred; OR . negative dengue virus IgM antibody test and no neutralizing antibody test performed *Epidemiologic link defined as one or more of the following: . Resides in or recent travel to an area with known ZIKV transmission, OR . Sexual contact with a confirmed or probable case of ZIKV infection or person with recent travel to an area with known ZIKV transmission; OR . Receipt of blood or blood products within 30 days of symptom onset; OR . Organ or tissue transplant recipient within 30 days of symptom onset; OR . Association in time or place with a confirmed or probable case; OR . Likely vector exposure in an area with suitable seasonal and ecological conditions for potential local vectorborne transmission

76 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Zika infection, congenital Confirmed: A neonate who does not meet clinical criteria for congenital Zika disease, . Detection of ZIKV by culture, viral 50222 BUT who meets confirmatory laboratory criteria. antigen or viral RNA in fetal tissue, umbilical cord blood, or amniotic fluid Probable: A neonate who does not meet clinical criteria for congenital Zika disease with a validated diagnostic test whose mother has an epidemiologic link* OR meets laboratory criteria for recent ZIKV or flavivirus infection; AND the neonate has laboratory evidence of recent ZIKV or OR flavivirus infection by: . Detection of ZIKV by culture, viral . Positive ZIKV IgM antibody test of serum or CSF within 2 days of birth**; AND antigen or viral RNA in neonatal serum, . positive neutralizing antibody titers against ZIKV and dengue or other CSF, or urine collected within 2 days of birth** flaviviruses endemic to the region where exposure occurred; OR . negative dengue virus IgM antibody test and no neutralizing antibody test OR performed . Positive ZIKV IgM antibody test in umbilical cord blood, neonatal serum or *Epidemiologic link defined as one or more of the following: CSF collected within 2 days of birth** . Resides in or recent travel to an area with known ZIKV transmission, OR with positive ZIKV neutralizing antibody . Sexual contact with a confirmed or probable case of ZIKV infection or person with titers and negative neutralizing antibody recent travel to an area with known ZIKV transmission; OR titers against dengue or other flaviviruses . Receipt of blood or blood products within 30 days of symptom onset; OR endemic to the region where exposure . Organ or tissue transplant recipient within 30 days of symptom onset; OR occurred . Association in time or place with a confirmed or probable case; OR . Likely vector exposure in an area with suitable seasonal and ecological conditions for potential local vectorborne transmission **The requirement that samples be collected within 2 days only applies to areas with ongoing local Zika transmission.

77 Revision date: January – October 2020

Condition/Code Case Definition/Case Classification Laboratory Confirmation Tests

Zika infection, non- Confirmed: An individual who does not meet clinical criteria for non-congenital Zika . Detection of ZIKV by culture, viral congenital disease, BUT who meets confirmatory laboratory criteria. antigen or viral RNA in serum, CSF, 50221 tissue, or other specimen (e.g., amniotic Probable: An individual who does not meet clinical criteria for non-congenital Zika fluid, urine, semen, saliva) with a disease, BUT who has an epidemiologic link* AND laboratory evidence of recent ZIKV validated diagnostic test, or flavivirus infection by: . Positive ZIKV IgM antibody test of serum or CSF with: OR . positive neutralizing antibody titers against ZIKV and dengue or other . Positive ZIKV IgM antibody test in serum or CSF with positive ZIKV flaviviruses endemic to the region where exposure occurred; OR neutralizing antibody titers and negative . negative dengue virus IgM antibody test and no neutralizing antibody test neutralizing antibody titers against performed dengue or other flaviviruses endemic to *Epidemiologic link defined as one or more of the following: the region where exposure occurred. . Resides in or recent travel to an area with known ZIKV transmission, OR . Sexual contact with a confirmed or probable case of ZIKV infection or person with recent travel to an area with known ZIKV transmission; OR . Receipt of blood or blood products within 120 days of diagnosis; OR . Organ or tissue transplant recipient within 120 days of diagnosis; OR . Association in time or place with a confirmed or probable case; OR Likely vector exposure in an area with suitable seasonal and ecological conditions for potential local vectorborne transmission

78 Revision date: January – October 2020